The Sight Vol. 5

An annual Optometric Journal, THE SIGHT Volume 5, Issue 5 Published by: Nepal Optometry Students Society, 7th Executive
Body Copyright Nepal Optometry Students Society
Disclaimer
We have tried our best to make this publication errorless and evidence based. Nepal Optometry Students Society disclaims all liability and responsibility to any person regarding the events or the consequences that might arise here forth as a result of reliance to any contents in this publication wholly or partly. Statements published in the journal are attributed solely to the authors as designated and not the official perspectives of NOSS in any ways. For enquiries or comments: Nepal Optometry Students Society, NOSS Institute of Medicine BPKLCOS P.O. BOX 8750 Phone: 01-4 Fax: 977-1Email: nossnepal@gmail.com URL: www.optometrynepal.org.np
THE SIGHT Vol. 5, Issue 5, September, 2009
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THE SIGHT
Volume 5, Issue 5 September, 2009
Editorial
While browsing up the history, the term optometry was apparently first used in the 1890s to describe a profession that today encompasses independent health care professionals trained and licensed to diagnose and treat diseases and disorders of the visual system. Exploring days of yore, what we find is that it had originated from the very concept of glass and not beyond. It was the matter of primordial era when everything was different and so was the notion about optometry. Ages passed, and now this field has already crossed innumerable epoch-making milestones. Time, people and experimentation together revolutionized optometry to not but zenith, it seems now to be the hay day shortly reviewing the scenario overseas. Research has indeed been the prevailing backbone for all these credits. Coming back to Nepal, scenery is again different. Till date, 37 optometrists have been produced from Institute of Medicine, Nepal and some few are from across the border. Being a primary eye care provider, this number of optometrists seems to be a tiny drop in an ocean to serve for 25 millions of Nepalese population. On the other hand, the Global Initiative, Vision 2020:The Right to Sight mainly targets to work in the underdeveloped and developing countries like Nepal, not to mention other countless number of INGOs frog-marching to eradicate the avoidable blindness. The change is impossible unless governmental policy binds each and every useful manpower within country and its only after that for an organization are interlocked to achieve the common goal of Vision 2020. Effective machinery should be set from the national level that can proportionately address the grass-root level of people from every corner that in turn is possible only when expatriation of nationally produced expertise is thwarted. If not so, the premonition about tragic scenes cannot be wiped out when skilled manpower continue to stampede out of country and INGOs put forth their efforts in vain for long. Consequences might be worse as still thousands of people are vulnerable to go blind which could otherwise be prevented or cured; the prediction is not uncommon for poverty- laden and health-unaware public. It is our pleasure to exude the proudness for making this journal a reality. Nothing could stop it, it just flowed with time to be more scientific, novel and evidence-based. Editing, classifying and arranging articles were just out of our imagination yet it was done with a hope of golden sunshine of tomorrow. Warm gratitude is due to all whoever has helped us either by providing articles or by supporting morally/financially and by any other means. This journal unquestionably proves that optometry education has made a leviathan leap despite limitations and obstacles. But still we have got a long and long way to go
THE SIGHT Vol. 5, Issue 5, September, 2009
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THE SIGHT
Volume 5, Number 1 September, 2009
In this Issue
Suman Adhikari Shajan Adolph Dr. Kuldeep Raizada Prakash Paudel Jyoti Khadka
01 02 05
Secretorial Desk Invited Article Coatings- A relook into this exciting segment Ocular Prosthesis: A Necessity of Ocular Disfigurement
Guest Articles
Primary eye care: Our achievements and future strategies A short perspective on Low vision aids for children Original Articles Induced Astigmatism in Sutureless Small-Incision Cataract Surgery using a Superior and Temporal Incision Profile of contact lens use in Mechi Eye Care Centre Profile of binocular visual status of pediatric patients presenting with the complaints of asthenopia Profile of amblyopia in children attending Sagarmatha Chaudhary Eye Hospital, Lahan School Eye Screening in Kathmandu Valley Review Articles Review on Care of Silicon Hydrogel Contact lens Eye Banking and corneal donation - Giving the Gift of Sight An overview on Coats Disease Eye Care Outreach Programs in Nepal: Who are the beneficiaries? Understanding People who are Visually Impaired Progressive addition lenses: What neophyte wearers and practitioners must know?? Management of Pediatric Cataract: A team approach Imaging of the Orbit (CT and MRI) Quality of life in low vision patients Ocular Malingering: Diagnosis and Management Pediatric Visual Impairment Stroke and Eye Family of Visually Impaired Child Clinical Pearls Know your Patients Mini-abstracts Gauri Shankar Shrestha Dr. Meenu Chaudhary Dr. Lila Raj Puri Dr. Subodh Gnyawali Dr. Sanjeev Bhattarai Nabin Paudel Ajit Thakur Surendra Dhungana Rajendra Gyawali Rabindra Adhikary Mahesh Kumar Dev Suraj Upadhyaya Sudan Puri Sanjaya Marasini Dinesh Kafle Digen Sujakhu Faithmath Nestha, Dipesh Bhattarai Nabin Raj Joshi Raju Kaiti, Sarita Manandhar
17 19 21 09 14
THE SIGHT, Volume 5, Issue 5, September, 2009
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THE SIGHT
REVIEW ARTICLE
An overview of Coats Disease

Lila R. Puri, MD
Introduction Coats disease was first described by George Coats in 1908. It is a condition of undetermined etiology characterized by telangiectatic and aneurysmal retinal vessels associated with sub-retinal and intra-retinal exudation in otherwise healthy individuals. It is a sporadic nonhereditary condition that is not associated with identifiable systemic abnormalities. It has no apparent preponderance for race but has a clear predilection for sex, with 75% of cases occurring in males. The disease has been reported to occur in children as young as 4 months of age, and some speculate that there might be some manifestation of the process already at birth. The average age of diagnosis is 8 to 16 years, and among the individuals with the juvenile form of Coats disease, two-thirds develop clinical manifestation by the age of 10 years. Approximately one-third of patients do not present with symptoms until after the age of 30. Mostly the disease is unilateral (95%). Pathophysiology The pathogenesis of Coats disease is vague but probably follows a general sequence of events. The telangiectatic blood vessels (presumably congenital) have more permeable endothelial cells. Hence, they leak lipoproteins into the retina, causing retinal edema. As this material accumulates, it eventually breaks through the external limiting membrane of the retina, causing a non-rhegmatogenous exudative retinal detachment. As further lipo-proteinous material accumulates, the retinal detachment becomes bullous. The long-standing retinal detachment can sometimes lead to neovascular glaucoma and other complications. Clinical features Most patients with Coats disease present with decreased vision, leukocoria, and strabismus. The anterior segment is usually normal. However, corneal edema, iris neovascularization, and anterior chamber cholesterolosis can be seen in eyes with total retinal detachment and secondary neovascular glaucoma. The heterochromia seen in Coats disease usually is due to darkening of the ipsilateral iris from iris neovascularization. The ophthalmoscopic features of Coats disease include retinal telangiectasia, intraretinal exudation, and exudative retinal detachment. The retinal telangiectasia usually is located in the peripheral retina, most often between the equator and ora serrata infero-temporally. It is characterized by areas of generalized capillary dilation with small aneurysms that cause focal enlargement of these dilated capillaries. Telangiectasia in the macular area is uncommon, occurring in 5% of cases. Occasionally, there are aneurysmal dilatations of the major retinal arteries and veins as well. The exudation usually involves the retina diffusely in 75% of cases, often affecting areas remote from the main vascular abnormalities (with a particular predisposition for the macular region). When the macular exudation is dense in the form of a gray white nodule, visual prognosis is worse. Patients with untreated Coats disease eventually develop a non-rhegmatogenous exudative retinal detachment. It generally begins in the areas of telangiectasia and slowly progresses to involve the entire retina. The subretinal material is golden yellow and often shows refractile crystals of cholesterol. The detachment can eventually lie immediately behind the posterior lens capsule and can progress to cause anterior displacement of the lensiris diaphragm and secondary glaucoma.
THE SIGHT, Volume 5, Issue 5, September, 2009
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Classification (proposed by Shields et al) Stage 1 Retinal telangiectasia only Stage 3: A 12Stage 2: ABTelangiectasia and exudation Extra foveal exudation Foveal exudation B. Stage 4 Exudative retinal detachment Subtotal detachment Extra foveal Foveal Total retinal detachment Total retinal detachment and glaucoma
Stage 5: Advanced end-stage disease Differential Diagnosis Children

Retinoblastoma Toxocara granuloma Congenital cataract Persistent Hyperplastic primary vitreous Retinopathy of pre-maturity Norries disease Familial exudative retinopathy Retinal angiomatosis
Adults
Diabetic retinopathy Retinal vein occlusions Juxtafoveal telangiectasias Arterial macroaneurysm Vasculitis Hemangiomas Familial exudative retinopathy
Perhaps the most important differentiation to be made is between Coats disease and retinoblastoma, given the potential morbidity and mortality associated with the latter condition. The advanced form of Coats disease may present as an exudative retinal detachment and dilated retinal vessels with the appearance of a retinal mass, mimicking retinoblastoma. In fact, among enucleated eyes discovered to be misdiagnosed with retinoblastoma, Coats disease usually happens to be the most common diagnosis. Association Coats syndrome or a Coats-like response (retinal detachment with massive subretinal exudation) has been seen associated with various other systemic and ocular diseases including muscular dystrophy, branch retinal vein obstruction, retinitis pigmentosa, Hallermann- Streiff syndrome, Turner syndrome and retinopathy of prematurity. Diagnosis The best method of making the diagnosis of Coats disease is recognition of the characteristic ophthalmoscopic features. It is important to obtain a medical and family history and to examine the patients parents to help exclude conditions like retinoblastoma, ocular toxocariasis, persistent hyperplastic primary vitreous, familial exudative vitreoretinopathy, and other childhood exudative retinopathies. Ancillary studies like Ultrasonography, fluorescein angiography, and cytologic analysis of sub-retinal fluid can be helpful in substantiating the diagnosis in atypical cases. Ultrasonography is mainly of diagnostic value in cases with a retinal detachment in which exophytic retinoblastoma is a consideration in the differential diagnosis. FFA can delineate irregularly dilated, tortuous blood vessels and adjacent areas of retinal capillary dropout that characterize Coats disease. The vessels typically fill with fluorescein in the late arterial or early venous phase and show progressive leakage of dye into the adjacent retina and sub-retinal space. In late-phase angiograms, there is persistent confluent hyperfluorescence of the exudate in the retina and sub-retinal space. Computed tomography and magnetic resonance imaging may also be useful in detecting masses, and computed tomography is very good at demonstrating calcifications.
Treatment THE SIGHT, Vol. 5, Issue 5, September 2009 Page 5
The goal of treatment is to obliterate the telangiectasis and stop the exudation. Multiple treatments may be required. The treatment modality depends on the location of the lesions and the age of patient. According to a recent report, the proposed classification of Coats disease can be helpful for selecting treatment and predicting the ocular and visual outcomes. Stage 1 disease (telangiectasia only) Can be managed by either periodic observation or Laser photocoagulation. Stage 2 disease (telangiectasia and exudation) Cryotherapy or Laser photocoagulation depending on the extent of the disease Stage 3A disease (subtotal retinal detachment) Laser photocoagulation or cryotherapy. Stage 3B disease (total retinal detachment) Can be managed with cryotherapy if the detachment is shallow, but surgical reattachment may be required if the retina is immediately posterior to the lens. Stage 4 disease (total retinal detachment with glaucoma) Often best managed by enucleation to relieve the severe ocular pain. Patients with stage 5 disease Generally have a blind, but comfortable, eye and require no aggressive treatment. References
1. 2. 3. 4. 5. 6. Egerer , Tasman W, Tomer TL. Coats disease. Arch Ophthalmol. 1974;92:109112. 156 Reese AB. Telangiectasias of the retina and Coats disease. Am J Ophthalmol. 1956;42:18. Asdourian G. Vascular anomalies of the retina. In: Peyman GA, Sanders DR, Goldberg MP, eds. Principals and Practices of Ophthalmology. Vol. 2. Philadelphia: WB Saunders; 1980. Shields JA, Shields CL, Honavar SG, et al. Classification and management of Coats disease: the 2000 proctor lecture. Am J Ophthalmol. 2001;131:572583. Tarkkanen A, Laatikainen L. Coats disease: clinical, angiographic, histopathological findings and clinical management. Br J Ophthalmol. 1983;67:766776. Woods AC, Duke J. Coats disease. I. Review of the literature, diagnostic criteria, clinical findings, and plasma lipid studies. Br J Opthalmol. 1963;47:385412. CRB1 in inherited blindness. Novartis Found Symp. 2004;255:6879.
Lila R. Puri, MD
Ophthalmologist EREC-P, Sagarmatha Chaudhary Eye Hospital, Lahan, Nepal Email: drlila_raj@yahoo.com
THE SIGHT, Vol. 5, Issue 5, September 2009
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THE SIGHT
REVIEW ARTICLE
Eye Banking and corneal donation - Giving the Gift of Sight

Dr. Meenu Chaudhary, MD
The joy of sight restoration is incomparable with anything in the world. It is like giving life back to the dead. Anyone who has spent time in Asia or Africa can invariably recall a vivid image of a blind beggar, sometimes an elderly person but frequently a child with opaque corneas, haunting the bazaars and marketplaces of cities and villages. The spectre is so common that it almost passes unnoticed, but these individuals who are bilaterally blind represent only a small fraction of the millions who suffer monocular blindness as a result of corneal trauma and subsequent microbial keratitis. With the global figure of blindness rapidly approaching 40 million, attention naturally is focused on cataract, which is responsible for 50% or more of all visual disability. While corneal blindness in the developing world has traditionally been attributed to Trachoma, Xerophthalmia, Measles, Neonatal ophthalmia and Leprosy, Thylefors contends that the importance of superficial corneal trauma in agricultural work, which frequently leads to rapidly progressing corneal ulceration and visual loss, has been overlooked as a worldwide cause of monocular blindness. In National Blindness Survey (1981), corneal trauma and ulceration were found to be the second leading cause of unilateral visual loss after cataract, accounting for 7.9% of all blind eyes. In Malawi, Tanzania and Bangladesh corneal scarring was found to be responsible for 39-55% of all cases of unilateral blindness. Undoubtedly, true estimates of the magnitude of blindness from corneal ulceration in the developing world remain elusive because of the unilateral nature of keratitis. A comparison of population based studies in the USA and India indicates that there is at least a tenfold higher incidence of corneal ulceration in India. In absolute numbers, microbial keratitis in the developing world is a previously undocumented significant cause of THE SIGHT, Vol. 5, Issue 5, September 2009 monocular blindness. As such, even by conservative estimates, it is responsible for well over one and a half million new cases of unilateral blindness worldwide each year. Corneal blindness is a major form of visual deprivation in developing countries. A high percentage of these individuals can be visually rehabilitated by corneal transplantation, a procedure that has very high rate of success (about 90%) among organ transplants. Quality of donor cornea, the nature of recipient pathology and the availability of appropriate postoperative care are the factors those determine the final outcome of this procedure. On December 7, 1905, Dr. Edward Zirm performed the first successful and permanent corneal transplant. The procedure was performed on Alois Glogar, a farmer who was suffering from the consequence of chemical eye burns. The cornea was of an 11-year-old boy named Karl Brauer. Understanding that the second major cause of blindness in Nepal is corneal blindness and that an estimated 1,200 men, women and children could be helped each year through the establishment of an eye bank, Nepal Eye Bank was established on September 16, 1994 at Tilganga Eye Centre with the generous help of IFEB and Indian Eye Bank, which reached out in a generous caring way to bring hope and vision to the citizens of Nepal. In 1999 Temple Eye Banking was started by Tilganga eye hospital for procuring cornea. Eye Bank An "Eye Bank" is a nonprofit community organization governed by a Board of Directors or Trustees constituted by community representatives. Structurally, it has administrative and medical Page 7
components. The entire operation is supervised by a Medical Director, who is usually a well qualified corneal surgeon assisted by an Administrator and other staff on the administrative aspects and trained technicians on the medical issues. Functionally, the administrative section is responsible for public awareness programs, liaison with government, local voluntary and other health care agencies and fund raising. The medical section deals with the entire technical operation of the eye bank. Tissue harvesting, tissue evaluation, tissue preservation and tissue distribution represent these activities. Each of these should be carried out following medical standards of highest quality. Any deviation from accepted medical standards can result in devastating complications. Procurement and supply of donor cornea to the corneal surgeons is the primary goal of eye banks. The Eye Bank is responsible for the collection and processing of donated tissues, their distribution and is also liable for an extensive public awareness program that can dramatically improve donation rates and public receptivity to eye donation. Moreover, it performs necessary blood investigation for HIV/AIDS, Hepatitis B, Hepatitis C and Syphilis of the Donor. An eye bank should have communication facilities, access to equipment such as slit lamp and laminar flow hood, surgical instruments, sterilization facilities, serology laboratory, preservation media and appropriate transportation system. Round-the-clock coverage by fully trained technicians is essential. All eye banks should be part of a nationwide network to facilitate optimal utilization of all corneas found suitable for corneal transplantation.
Corneal donation all begins with a donor and a donor family. Death of a loved one is never easy. The gift of eye, organ and tissue donation not only benefits the transplant recipients, but also eases the pain and grief of a donor family by offering a measure of comfort. When preliminary donor suitability has been determined and consent has been granted by the family, trained health professionals begin the process of eye recovery. This surgical procedure, known as enucleation, is usually accomplished within six hours of death and preservation of the corneas generally takes place within 12 hours of death. After the eyes have been delivered to the eye bank, they are carefully examined, and the corneas are surgically removed in a sterile environment. The corneas are placed in protective sterile chambers containing a preservation media that enables refrigerated storage for a number of days. Surgeons are notified of the availability of suitable corneas. Corneal matching is not necessary, as a lower level of rejection occurs than in solid organ transplant probably due to the avascular nature of the cornea. Nevertheless, rejection is always a possibility. If a transplant fails, the patient can undergo another corneal transplant at a late time. Our appeal Take pledge to donate your eyes Motivate and educate others about eye donation. Call your nearest eye bank. Restoring sight through the promotion and advancement of eye banking, thanks to heroic and compassionate donor families, many have received The Gift of Sight.
Dr. Meenu Chaudhary, MD

Lecturer, Cornea specialist BP Koirala Lions Centre for Ophthalmic Studies, IOM Maharajgunj, Kathmandu Email:
Before
After
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Understanding Visually Impaired People- Bhattarai
Frequently Asked Questions about Corneal Transplantation What is Corneal Transplantation? A Corneal transplant is a surgery which replaces the opaque cornea with a clear cornea obtained from a human donor eye. 2. How does a cornea become opaque? Infection Injuries Malnutrition Congenital/Hereditary 3. Who can be an eye donor? Practically, anybody from the age of 1 year can be a donor. There is no upper age limit. Spectacle wearers, people who had had cataract surgery, diabetics and hypertensive, and even people blind from retinal or optic nerve disease can donate their eyes. The ultimate decision about usage for transplantation will be made after evaluation. 4. Can the next-of-kin consent to a donation if the deceased family member hasn't signed a pledge form? Yes. 5. How can I be of help on the death of a close relative or friend? Motivate the next of kin of the deceased person to donate their eyes. Eyes need to be collected within 6 hours of death. Call your nearest eye bank at the earliest. You are authorized to donate the eyes of your beloved relatives at the time of their death, even if a pledge for donation has not been made earlier by the deceased. 6. What should I do till the Eye Donation team arrives? 1.
Keep both eyes of deceased closed and covered with moist cotton. Switch off the overhead fan. Raise the head end of the body by about 6 inches, if possible - to decrease the incidence of bleeding during the removal of the
eyes.
If possible, instill antibiotic eye drops periodically.

7. Who cannot be a donor?
Death from unknown cause. Death due to infectious caused viz. Rabies, Syphilis, Infectious Hepatitis, Septicemia and AIDS. Any frank ocular infection, previous refractive surgery.
8. Can the whole eye be transplanted? No. Only the cornea and sclera can be transplanted. However, the entire eyeball is enucleated, to enable the corneo-scleral disc to be fashioned surgically in a sterile environment. 9. Can a living person donate his/her eyes? No. 10. Can the recipients be told who donated the eyes? No. The gift of sight is made anonymously.
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Understanding Visually Impaired People- Bhattarai
THE SIGHT
REVIEW ARTICLE
Understanding Visually Impaired People

Dr. Sanjeev Bhattarai, M.Optom, O.D Low vision or visual impairment is a term used to describe varying degrees of vision loss that can not be corrected by medications, surgeries or conventional glasses and contact lenses. World Health Organization (WHO) defines - "A person with low vision is one who has visual acuity of less than 6/18 to light perception, or a visual field of less than 10 degrees from the point of fixation but who uses or is potentially able to use vision for the planning and/or execution of a task". Visual disturbances in low vision patients are loss of central and peripheral vision, overall blurred vision, night blindness, light and glare problems etc. Examination and Evaluation: Focus should be given on patient's concerns as people are extremely variable and all have individual interests and lifestyles. Reading, watching TV, activities of daily living and recreations, mobility, work and financial support, psychosocial conditions etc should be specially considered. Examination begins with vision assessment for near and far, contrast sensitivity function, visual field, glare test, color vision, binocular vision, refraction etc. Management: After examination procedures, depending on the patient's needs both optical as well as non optical devices can be given. Patients should be advised to optimize lighting conditions and contrast whenever it is required. Refraction should be aimed to obtain the best possible visual function. For near activities reading glasses, hand held and stand magnifiers, bar magnifier, Fresnel magnifier, reading telescopes, CCTV can be provided with proper training to utilize the instruments. For distance, telescopes can be given with varying magnification. Non-optical devices for low vision patients include many assistive devices like talking watches/clocks, writing guides, liquid level indicators, tactile controls, large playing cards, glare control devices, posture and comfort maintenance devices, THE SIGHT, Vol. 5, Issue 5, September 2009 written communication devices, sensory and audition devices, large print syringes etc. Low vision intervention can be very beneficial in diseases like Albinism, Diabetic retinopathy, Age related macular degeneration, High myopia, Aniridia, Retinal coloboma, Optic atrophy etc. Ocular conditions in which low vision devices can still be tried include Nystagmus, Advanced glaucoma, Microphthalmos, Congenital cataracts, corneal dystrophy, Marfan's syndrome etc. Understanding problems of visually impaired The impaired person waits for someone else for information. He/she depends more on verbal remarks. He/she needs more time to do the task. Do not always place objects in the person's hand. The person should be encouraged to look for the object and reach out for it. To make them adapt to their environment, ask relatives and friends to explain and describe objects and things happening. Describe these things in words that the person can understand. The clinician should describe him/herself after entering/leaving the room as they may not be aware of another person nearby or in a room. Provide objects or materials with contrasting colors that make activities easier. People with certain eye conditions are nearly blind at night or in dim light. They may not have enough vision to move safely by themselves or do their normal activities as they could do during the day. A torch or flashlight is useful. It is often difficult to see steps or changes in the level of floors or the ground. Changes in the levels can be marked. Objects are usually easier to see when they are large and close. Page 10
Understanding Visually Impaired People- Bhattarai They find it easy to detect colorful objects. Glare makes it difficult for all people to see. The light in the environment and on objects can affect how well objects can be seen. Sitting close to TV at a distance which is comfortable for the eyes will not cause any damage. It is not wrong to squint and view the faces or objects if someone sees better by doing so.
Some myths and suggestions for visually impaired which should be explained to the patient and relatives are as follows: The brightest possible light is not necessarily the best. Visual effort will produce no ocular damage though there may be an initial fatigue, which will be overcome by regular usage. The more the visually impaired person uses his residual vision, the better the brain will interpret. Its good to sit in natural day light and read initially till the adaptation to the low vision device occurs.
Conclusion: A low vision patient should be assured of some attention with patience to explore the possibilities of assisting him/her even if they are of very little help. The modern optical, non-optical and electronic devices though cost prohibitive, have opened the doors to light from darkness.
References:
1. Essentials of low vision Richard L Brilliant
2. Understanding low vision Randall T Jose 3. Practice of low vision-A guide book- E. Vaithilingam 4. Oxford hand book of Ophthalmology. 5. Essentials of Ophthalmology-Samar Kumar Basak
Dr. Sanjeev Bhattarai

Instructor Optometrist BP Koirala Lions Centre for Ophthalmic Studies Institute Of Medicine Email: bhattarai_sanjeev@yahoo.com
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Eye Care Outreach Programs in Nepal Gyawali
THE SIGHT
REVIEW ARTICLE
Eye Care Outreach Programs in Nepal: Who are the beneficiaries?

Subodh Gnyawali, OD
By making the elimination of needless blindness its prime objective, VISION 2020 has introduced a major paradigm shift in the planning and delivery of eye care. With adoption of Vision 2020 program by the Government of Nepal, for many service providers and other stakeholders in this global initiative, this is both a challenge and an urgent call to move quickly from reaching as many as we can strategies to new approaches that insist on doing it right and enough to make a lasting impact. It is quite challenging to make it happen in the poorest and neediest rural communities of Nepal with dysfunctional infrastructure, limited access to and use of existing eye care services. Outreach should be defined as the provision of a specialized service to a location outside the normal service catchment area of the hospital. To be optimally effective, outreach strategies must be grounded in, and guided by, a clear understanding of the inequitable nature of many eye care services. Those who need eye care services the most are often the last to have access to them, if at all. This may be so even when these services are brought closer to their communities, though several studies have shown that the utilization of health services by deprived groups increases when service providers reach their locality. So, unless specific proactive measures are put in place to seek them out, eye care outreach programs will remain ineffective in delivering services to the un-served. Different eye health institutions sometimes, with support from international organizations, have conducted several outreach programs (either surgical, screening, mobile eye camps or community based rehabilitation camps) in different parts of the country at different times. Most outreach programs can easily result in increased number of patients seen or offered surgery. The real challenge, however, is ensuring their administrative, organizational THE SIGHT, Vol. 5, Issue 5, September 2009 and financial sustainability for long term, something that only few institutions or organizations have done successfully so far. The current gap between eye care providers and the many blind and severely visually impaired needing their services is unacceptable, and could be best bridged through the establishment of permanent eye care structures and services. Some of the major barriers for blind people are actually within the first 100 meters of their front door. These communities are isolated; suffer from poor infrastructure, and a low-density population, which prohibits the establishment of a high volume surgical unit. The most effective way to reach these communities has been to train and integrate primary eye care workers into the existing primary health care systems. Ideally, a resident of these communities is identified and trained for this work what most projects call a community-based rehabilitation (CBR) worker. These primary eye care workers are best placed to penetrate the 100-metre barrier that exists around a blind persons home. Non Governmental Organizations who conduct free eye camps and provide eye glasses only with the idea "providing some care is better than providing none" are at times counter productive and can prevent patients from seeking eye care for other ophthalmic conditions. Such short term intervention can be wasteful, unethical, and harmful and often serve as medical tourism. They fail to partner with local health care bodies and undermine the local health care system. Though few would question the honorable intentions behind these types of interventions, short-term missions rarely produce tangible, lasting medical benefits in local communities. Rather, they tend to be self-serving, ineffective, and provide only temporary, limited care without addressing the fundamentals of eye care needs. Page 12
Finally, there is generally no follow-up or quality control with these types of trips; most of these missions identify their success based on whether a patient smiles upon receipt of the glasses, or whether the team is invited back for a future mission. These are not effective metrics for evaluating success. Eye care programs must eliminate patient barriers to care by fully funding surgeries, bringing eye care services to the patients, providing transportation to the eye hospitals for surgery as needed and educating communities about blindness elimination. Prescribing eyeglasses only during a short-term intervention to population will leave them believing they have received a complete ophthalmic exam, no matter how cursory the vision screening, even if they are explicitly told otherwise. If a patient with cataracts, for example, is told that eyeglasses will not correct their sight, but an option for subsidized or free cataract surgery is not provided, the patient will continue to believe that nothing can be done to restore their sight. Random spectacle distribution, above that by a non eye care professional, breaks the chain of patient care and is counterproductive as it can cause discomfort to the wearer and create or perpetuate distrust of health providers. Training community members to prescribe eye glasses can have a negative effect on the identification and treatment of curable and treatable eye diseases. Referring patients from rural communities to their local eye doctor without reducing the barriers will not enable their access to locally available resources and quality eye care. Of all the worst effect is seen with short term surgical missions. There is no provision of follow up care which
Eye Care Outreach Programs in Nepal Gyawali is very important to tackle post-operative complications. Local doctors are often left to deal with complications following low quality surgeries, which is both timeconsuming and a financial burden to the local clinics. Such interventions are thus minimally effective at best, as they do not encourage community members to seek regular eye care, nor do they build local capacity. Another disastrous effect is seen with the distribution of contaminated and expired medicines in outreach clinics. Expired medications often degrade into toxic substances, and lowered drug efficacy may lead to patients receiving incorrect or ineffective dosages. With regards to ophthalmic surgery, the post-operative use of ineffective expired drugs can lead to infection and the consequent loss of vision. Particularly with antibiotics, expiration and contamination can not only harm patients, but contribute to the ever-worsening global problem of microbial resistance. Thus such communities may serve as dumping zones for pharmaceutical junk. Some of the key components of a good outreach program can be summarized under following heads: 1. Careful planning of the program 2. Community involvement and ownership 3. Government involvement and leadership 4. A good monitoring and evaluation system 5. A structure and clear mechanisms for dialogue, problem-solving and co-ordination among all stakeholders Subodh Gnyawali, OD
MPH Student, Institute Of Medicine Maharajgunj, Kathmandu, Nepal Email: subodh_neh@hotmail.com
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Coatings - Adolph
THE SIGHT
REVIEW ARTICLE
Coatings- A Relook into This Exciting Segment

Shajan Adolph, Fellow in Optometry, FIACLE Lens coating has become a hot topic in the optical fraternity and one may wonder why so much of hype on this segment. But the reality is that it requires much more attention than this as this segment is not yet established well in many markets and countries. Spectacles are considered as a friendly aid to help us in achieving better visual performances. Considering the modern life style and work profile, one is constantly engaged in many activities and almost all kinds of jobs require precise vision and the visual demand is on rise on daily basis. Improved visual quantity and quality, better contrast, reduced reflections and glare, better color perception etc. are becoming mandatory for every one. ECP (Eye Care Professionals) need to note and accept the change that new generation is looking for an opportunity to SEEING WELL and not just seeing. Unfortunately the regular pairs of uncoated lenses are not equipped to fight against the common enemies of spectacle lenses like scratches, reflections, smudges and deposits and hence the need of AR coating comes to the scene. Coating on lenses started in 1950s with glass lenses and later plastics and polycarbonate lenses also joined in due time, offering many options for the ECP. While it is true that coating provides much value addition to the lenses, the coating process is a very complicated one. The success of coating lay up on many factors including the right selection of materials for coating, process control in coating unit, quality of the lens materials etc. Thanks to the advanced technology and advancements in the software industry, more precision is achieved today in the coating and we have a good number of labs providing quality lens coating. Coatings can be broadly divided into the following categories: Hard coating or commonly called Scratch resistant coating (HC) Hard Multi Coating or Anti-reflection coating (ARC) Hard-Coatings: Hard coatings are meant to protect the surface of the lens by resisting the scratches and hence increase the life of the lens. Customers change their lenses only after two or two and half years on average. Only a good hard coat can withstand the wear and tear of such a long time. From the umpteen products available in the market at different price points, it is wise to provide a good quality hard coat to protect the investment of customers. Promoting hard coat requires a good understanding of the technology, materials and process as these are the main factors behind the success of HC. It is difficult to filter out a good HC from an ordinary one in the counter of an optical outlet as all lenses look transparent or WHITE. There are many lab tests which tell us the quality and efficiency of the HC but there are no counter tests to check the same. Usually the counter sales team gets the confidence on the products from the response of the end users. Hard Coating is meant for resisting the scratches which comes while handling the lenses and can not be termed as scratch proof coating. It is a fact that the lenses, especially plastic segment became more user friendly after the advent of HC. There are different materials available for hard coating and processing is also an important factor. The bonding between basic monomer and hard coating varnish has to be good for the long lasting performance of the lens. ECP need to understand the features and benefits of the products. There are few Page 14
Coatings - Adolph proven products in the market which are trusted and certified both by wearers and Opticians. Anti-Reflection coating One of the most anointing concerns of the spectacle wearer is the reflection from the lens surface which not only reduces the quality of vision but also hampers the cosmesis. Due to the changed life style one is exposed to different kinds of lights, contrasts, ghost images, reflections and glare etc. While it is true that all spectacle users suffer from these problems, the issues are much more with people who spend maximum time infront of the computers/monitors and also with night drivers. Reflections When we see an object, the entire amount of light beam from the object should pass through the lens and focus on retina. But this sort of ideal scenario does not exist and some amount of light gets reflected back from the lens surface. Reflections depend on many factors like refractive index, thickness and curvature of the lens, lens surface quality etc. Reflections with ghost images pull down the quality of vision and it has to be addressed well to have better visual experience. How does AR coating work? AR coating has to be done after the hard coating and multiple layers of different chemicals (oxides) are applied on either surface of the lenses in a highly controlled atmosphere, using vacuum technology. The process runs under stringent quality controls as variations in the temperature, humidity etc. can affect the quality of ARC. After ARC is applied, some manufacturers use hydrophobic coating which makes the lens surface easy to clean. Manufacturers have different materials to use for coating and depending on the chemical used, lens get a residual color which helps us to differentiate AR coated lenses from uncoated or hard coated lenses. The residual color has no connections with the efficacy of the coating however most preferred colors are green and blue. The functioning of AR coating is simple. The reflected rays from the lens surface can be considered as positive waves and the AR coating creates negative waves and THE SIGHT, Vol. 5, Issue 5, September 2009 cancels the reflection. In scientific terms it is called Destructive interference. The function of ARC may look simple but the processing is very complicated needing man, machine, money and time. The advancements in the tools and software helped us to achieve a greater level of standards in production. The combination of lens material and coating ensures a better durability of the coating and it is great challenge to the manufacturer. Making quality products available at best price and matching the delivery expectation from the outlets are the other challenges. AR Coating features and benefits A good ARC ensures elimination of reflection and increases light transmittance which ensures that you are seeing well and you are seen well as well. Glare reduction provides better visual quality and improved contrast is helpful in better color perception. The multiple layers also provide better surface clarity. ARC is beneficial not only for computer users but also for all spectacle wearers. Each and every one can have better vision with the help of ARC and hence the ECP need to advice ARC for the entire spectacle users and help them to see the world better. Why ARC use is less in our country? The use of ARC in the SAARC countries is very less compared to other Asian countries and the major reason for this is the lack of awareness. While some ECP are extremely well on this segment there is another group of practitioners who are not dealing with this at all. An active recommendation form the side of ECP along with the marketing support from the companies can bring up the use of ARC. Today companies like Essilor join with optical fraternity to promote this segment well. ARC Cost a concern At times the counter sales team members are not in a position to explain well about the benefits of ARC and the consumers either get a negative message or they do not find any value with this coating. As we know that cost is a relative term and if properly explained the benefits by the counter sales team, consumers get better idea about ARC and it results in a better sale. The cost is justified if consumers understand the benefits of ARC. Education on ARC is a major task taken by many Page 15
Coatings - Adolph companies as this will help towards making ARC a preferred option for the end users. ECP has a wide choice of products available now in market ranging from the lowest range to premium. A good quality product is selected on the basis of its performance, technology, availability and brand value. The negative remark on ARC is the coating peel off and it is mainly due to the poor selection of products, improper use of lenses by consumers and at times even due to the poor quality of lens coating. We have better quality of coating nowadays which are very durable and ECP can make a wise choice after considering few parameters. Essilors Crizal is one of the leading and most trusted ARC products in the world. A good quality product protects the investment of the end users while delivering the benefits. Business Opportunity A recent survey done by Essilor reveals that ARC penetration is too low in many Asian countries for e.g. in India it is only 6% while other countries like Japan has 98% penetration. The survey results also reveal some interesting factors like more than 90% of people are willing to buy ARC and 98% of the end users are willing to buy the lenses again. The potential for ARC is very high and ECP have to capitalize this opportunity and prepare their sales team for the change. Future of ARC The retail business is emerging well in all spheres and economy is also showing a great future ahead. Consumer awareness, organized selling styles, educated sales team, better products etc are all predicting a bright future for this segment. ECP have to gear up for this and equip themselves to welcome the new era of ARC.
Shajan Adolph
Fellow in Optometry, FIACLE Head of Professional Services, Essilor India Email: shajan@essilorindia.com
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Review on care of silicon hydrogel lenses - Shrestha
THE SIGHT
REVIEW ARTICLE
Review On Care Of Silicone Hydrogel Lenses

Gauri S. Shrestha, BOptom, MOptom
In the last few years, silicone hydrogel contact lens has surpassed tremendous breakthrough over traditional hydrogel lens as daily or flexible wear and has opened the hope of continuous wear for 30 days. These new generations of "super-permeable" contact lenses can transmit unprecedented amounts of oxygen to cornea that breathe six to seven times more oxygen than previous lenses. U.S. Food and Drug Administration (FDA) has approved Day & Night (CIBA Vision) and PureVision (Bausch & Lomb) to be worn for 30 days. Acuvue Oasys (Johnson and Johnson), and O2Optix (CIBA Vision) are approved for overnight wear of six nights consecutively.1 When a lens remains on the eye for a long period; metabolic debris, including CO2 and lactate, forms under the lens. Exotoxins produced by normal eyelid flora may also accumulate and are effective in inciting inflammatory reactions. So, removal of post-lens ocular waste is still not applicable for higher Dk materials designed for continuous wear and lens care regimen is important for silicone hydrogels also.2 Currently, five solutions have an FDA indication for silicone hydrogel lenses: Aquify MPS and Clear Care (CIBA Vision); Opti-Free Express and Replenish (Alcon); and ReNu with MultiPlus (Bausch & Lomb). There has been marked growth in the use of no-rub care regimens. This idea primarily came about because of its well recognition that patients are generally noncompliant with instructions relating to the rub-and-rinse step, with many merely removing the lens from their eye and dropping it into their care regimen overnight. These no-rub products were developed to work optimally on the large amount of loosely bound, non-denatured protein that is found on many conventional lens materials. Unlike conventional lenses, silicone hydrogels deposit small amounts of denatured proteins and THE SIGHT, Vol. 5, Issue 5, September 2009 increased amounts of lipid and thus there is growing evidence to suggest that patients using silicone hydrogels should consider rubbing their lenses with their care regimen.3 Antimicrobial and Disinfection Efficacy Though, the risk of infection in the extended wear lenses is comparable to that of older lens types worn for fewer nights, acanthamoebal attachment to the silicone hydrogel is greatly significant. The inherent characteristics of the polymer or a side effect of the surface treatment procedure are supposed to be the cause. 4 Currently there are no agreed test organisms or standards to which solutions must conform in their efficacy against acanthamoeba. In fact, multipurpose solutions having an effect on acanthamoeba works by simple physical removal or some level of disinfection. 5 According to the stand-alone primary criteria of FDA Guidelines, ReNu and ReNu MultiPlus meets the acceptance criteria for stand-alone disinfectants against all challenging organisms: Staphylococcus aureus, Serratia marcescens, Pseudomonas aeruginosa, Candida albicans, and Fusarium solani.6 ReNu MultiPlus (Bausch & Lomb), AOSEPT (CIBA Vision), and Opti-Free Express with Aldox (Alcon Laboratories) are the only lens care products that met the stand-alone criteria for all required microorganisms within their minimum recommended disinfection time (4 hours). 7 Surface Deposit Proteins, lipids and mucin deposit rapidly after lens insertion. Tear proteins include lysozyme, lactoferrin and albumin, with lysozyme accounting for 90% of the total lens protein deposits. In its natural state, lysozyme is a bacteriolytic enzyme, however once it deposits on a lens, it gets denaturated, which may incite an immunological response, such as contact lens papillary Page 17
conjunctivitis (CLPC). This positively charged protein is also easily absorbed by negatively charged materials with relatively large pore size. This is more prominent in HEMA material combined with group IV polymers. Most of silicone hydrogel falls under the FDA categories I & III. Silicone hydrogel materials, on the other hand, have shown reduced protein deposition, but they show a greater percentage of denatured lysozyme.8, 9 Jones and colleagues9 reported silicone hydrogel contact lenses deposit more lipid than HEMA soft lenses do. The hydrophobic nature of silicone is presumed to be the responsible factor.8 Lipids deposited on the surface of high water non-ionic hydrogel as well as low water ionic silicone hydrogels are factors for the increased corneal staining.5 Lipids are easily removed with digital rubbing of a surfactant cleaner. They are also readily dissolved in solvent (alcohol) based cleaners such as MiraFlow (CIBA Vision).10, 11
Review on care of silicon hydrogel lenses - Shrestha Wettability Silicone hydrogel lenses are notorious for their high wetting angles and poor wettability. Surfactants found in contact lens solution help to increase wettability. A surfactant agent has both a hydrophilic and a hydrophobic end to its structure. In the case of a surfactant wetting agent, the hydrophobic end interacts with the dry hydrophobic lens surface, allowing the lens surface to regain hydrophilicity. A surfactant wetting agent decreases surface tension, significantly reducing dry areas. The substantivity (the length of time the surfactant stays on the lens) determines the longevity of this effect. Some large molecular proteins, like albumin, actually aid in the wetting of the lens surface. Smaller proteins, such as lysozyme and mucin, have no impact on the wettability of silicone hydrogel lenses.8 Lens and Solution Compatibility All contact lens materials may not be compatible with all
Solution & lens combination staining on selected lenses Unisol saline Acuvue 2 Pure vision Acuvue oasys O2 optix Focus daynight 1% 2% 2% 2% -4 Opti-free express -6% 3% 2% 4% Polyquad Opti-free repleniSH 5% 7% 5% 5% -ReNu MultiPlus 25% 6% 10% 7% 6% Biguanides Equate Complete moisture plus 2% 48% 5% 18% -
Aquify
1% 71% 12% 41% -
-21% 1% 7% --
1. Acceptable staining (<10%) Marginal staining (10%-20%) Unacceptable staining (>20%) 2. Andrasko G, et al. Compatibility of Silicone Hydrogel Lenses with Multi-Purpose Solutions. ARVO Poster, 2006
Wearing Modality Although many patients aspire to achieve 30 days of continuous lens wear, not all of them can successfully keep a lens on the eye for one month at a time. Therefore, a contact lens care regimen truly is a necessity for all modalities.10 With continuous wear, one key to avoiding an adverse response is to ensure that only a clean and disinfected lens is inserted into the eye. To prevent an inflammatory adverse event, many practitioners encourage their patients to only wear their contact lenses on a daily wear basis when they're ill and to return to overnight wear of their lenses when they're completely well.10 THE SIGHT, Vol. 5, Issue 5, September 2009
lens solutions. Biocides have different uptake and release patterns depending on the material, with the greatest corneal staining between two and six hours after lens insertion. 8 Opti-Free RepleniSH (Alcon), AQuify and Clear Care (CIBA Vision) have specific FDAapproved, "silicone hydrogel" labeling on the packages. UltraCare (AMO) is specifically contraindicated for use with PureVision lenses on the package insert.8 Polyhexymethylene biguinide (PHMB) disinfecting agents are most commonly implicated in solution-related corneal staining. PHMB has shown significantly more staining and tarsal plate changes compared with hydrogen peroxide and polyquaternium-based solutions.8 Page 18
However, not all PHMB solutions cause cytotoxicity with all lenses.8 Studies with silicone hydrogels indicate that the corneal staining seen is frequently annular in appearance, typically increases in severity over a 4-week wearing period.8 At the formulations of Aquify compared to Equate5, the concentration of PHMB is identical. The staining differences (Table) are influenced by other components in the formulation12. Although corneal staining is not a sight-threatening event, it probably does affect long-term wearing comfort. The compatibility of different lenses with different solutions in relation to corneal staining is presented in the following table: Last Message Regardless of refractive error, patient can get benefit of novel contact lens materials provided specific lens care recommendations are given to every patient based on the surface characteristics of the material, the patient's lifestyle and wear schedule. This is especially concerned while switching a patient from a conventional contact lens because previously used lens care solutions may no longer be appropriate. Observation of corneal staining can serve as a clue to incompatibility issues and compliance with contact lens care. Consideration of the lens care is an integral part of success with silicone hydrogel contact lenses. Not all lens care solutions are created alike and not all contact lens materials behave the same.
Review on care of silicon hydrogel lenses - Shrestha References:

1. 2. 3.
Liz Segre; Silicone hydrogel contact lenses; www.allaboutvision.com/advisorybrd.htm#Joseph Brian Chou, OD, FAAO; Are Silicone Hydrogel Contact Lenses Overrated? Contact lens spectrum Lyndon Jones, PhD FCOptom DipCLP DipOrth FAAO (DipCL) FIACL; Emerging Trends in New Care Regimens for Silicone Hydrogel CLs Materials, Silicone Hydrogel Tara K. Beattie et al; Enhanced attachment of Acanthamoeba to extended-wear silicone hydrogel contact lenses: A new risk factor for infection? Ophthalmology, Volume 110, Issue 4, Pages 765771 (April 2003) Nick Atkin; Development in lens care solutions; CET module C3 113; Optician; Feb 3,2006, No 6037Vol 231 Lever AM, Miller MJ; comparative antimicrobial efficacy of multipurpose lens solutions using the FDA revised guidance document for industry: Stand alone primary criteria. CLAO J. 1999 Jan;25(1):52-6 Miller MJ et al; Disinfection efficacy of contact lens care solutions against ocular pathogens; CLAO J. 2001 Jan;27(1):16-22 Christine Sindt, O.D., F.A.A.O; Caring for silicone hydrogel lenses; Optometry management; issue: july 2006 Jones L, Senchyna M, Glasier MA, Schickler J, Forbes I, Louie D, May C. Lysozyme and lipid deposition on silicone hydrogel contact lens materials. Eye Contact Lens. 2003;29(1 Suppl):S75S79; discussion S83-S84, S192-S194. Smythe, Jennifer L, A New Generation of Contact Lens Care; Optometric Management, Mar 2005 Lyndon Jone, PhD FCOptom DipCLP DipOrth FAAO (DipCL) FIACLE; Silicone hydrogel and choice for care regime; Silicone Hydrogel; March 2005 Lens-Solution Interactions; Contact lens spectrum; August 2006. Schafer J, Barr J, Mack C. A characterization of dryness symptoms with silicone hydrogel contact lenses. Optometry & Vision Science; 2003.
4.
5. 6.
7. 8. 9.
10. 11.
12. 13.
Gauri S. Shrestha
Teaching Assistant BP Koirala Lions Centre for Ophthalmic Studies IOM, TU
Email: gs101lg@hotmail.com
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Profile of Amblyopia - Joshi
THE SIGHT
ORIGINAL ARTICLE
Profile of amblyopia in children attending Sagarmatha Chaudhary Eye Hospital, Lahan

Nabin Raj Joshi
Background Amblyopia is one of the common causes of childhood visual impairment. The information regarding the prevalence of sub types of amblyopia can help in the prioritized management of this condition and the profile can give a general idea about a case of pediatric amblyopia, more rationally. Methods This was a prospective hospital based observational study, evaluating the clinical profile of the amblyopic patients presenting to the pediatric OPD of Sagarmatha Chaudhary Eye Hospital (SCEH), Lahan. Results Out of 50 patients enrolled in the study, 62% (31) were of Indian nationality and 58% (29) were male. The mean age of the sample was 10.54 3.56 (mean standard deviation) years. The mean age of the first presentation was 8.32 3.56 years. The mean difference between the first onset of symptoms and presentation was 3.44 2.17 years. The main cause of amblyopia was hyperopic isoametropia (38%, n=19). Conclusions The lack of awareness about the disease and the consequent late presentation are significant hindrances to our health system if amblyopia is to be tackled well in the future .
Introduction Amblyopia (Gk. Blunt eye) is generally used in a restricted sense to denote reduced vision in an eye in the absence of any ophthalmoscopically detectable retinal abnormality or any disorder of the afferent visual pathway which might cause the defect.1 Amblyopia can be classified as functional or organic (lesions in the visual pathway). Either form sense deprivation or abnormal binocular interaction or both can cause functional amblyopia.2 Till now no study has been done to evaluate the profile of the amblyopic children presenting to SCEH, Lahan. Materials and methods Informed consent was taken from the guardian of the patient before the enrollment in the study. This was a prospective, hospital-based observational study. Amblyopia was defined as 1) a decrease in best corrected visual acuity (BCVA) by 2 or more lines in either eye without any pathology of the visual system compared to good eye. 2) unilateral decrease of more than 1 line of BCVA in case of any amblyogenic factors.
Definitions used for the diagnosis of types of amblyopia were as follows 1) Deprivation amblyopia The light sense deprivation caused by the media opacities, complete ptosis etc can cause deprivation amblyopia. 2) Anisometropic amblyopia The difference of 1 D of hyperopia and 3 D of myopia causes anisometropic amblyopia. 3) Isoametropic amblyopia- This is caused due to the presence of high refractive error in both the eyes, resulting into an impaired form sense. It includes bilateral hyperopes in excess of 3 D and myopia in excess of 5 D.3 4) Strabismic amblyopia It is caused by the presence of any strabismus in distance or near fixation or both. Patients with strabismus and refractive errors less than 1D spherical error and 0.5D spherical equivalent were included in this group. 5) Refractive and strabismic amblyopia In this type of amblyopia, strabismus is associated with refractive component more than that of the true strabismic amblyopia. 6) Deprivation and refractive amblyopia It includes amblyopia associated both with deprivation and refractive causes either anisometropia or isoametropia. Page 20
Profile of Amblyopia - Joshi 7) Deprivation and strabismic amblyopia It includes amblyopia associated with both abnormal binocular interaction and light sense deprivation. 8) Mixed amblyopia All deprivation, refractive and strabismic factors are involved. (Note The classification system used may not be a standard one but the standard term `combined amblyopia is avoided for the aggregated type of amblyopia because the various amblyogenic factors must be studied separately so that the effect of each factor and its interaction with the other factors can be studied in greater detail and the effect of the type of factor in the prognosis is also very well known. Deprivation factor is difficult to treat than strabismic and strabismic is more difficult to treat than refractive.4) Visual acuity was taken with Snellens chart. History was taken about the age of first presentation, the cause of presentation and the duration of the defect noticed before the first presentation. Refraction was done objectively by retinoscopy and subjective refraction was performed whenever applicable. Results Demographic profile Sixty two percent (31) patients were from India. Fifty eight percent (29) were male and 42% (21) were female. Four percent (2) had family history of bilateral amblyopia and it was due to bilateral high myopia. Age distribution The mean age of the sample was 10.54 3.56 years. The mean age of the first presentation was 8.32 3.56 years and 42% (21) presented after 10 years of age. Maximum number of patients presented to the hospital with the complaints of whitish pupillary reflex and blurring of vision, 20% each (10 patients in each group). One child (2%) presented with developmental delay. Sixteen percent (8) patients were identified at the hospital as they presented with minor trauma to the eye, 7 of them with sub-conjunctival hemorrhage. Visual acuity and refractive error in amblyopic eyes Mean visual acuity in the amblyopic right eye was 0.146 (6/41) and left eye was 0.23 (6/26). Mean hyperopia was THE SIGHT, Vol. 5, Issue 5, September 2009 4.67 D and mean myopia was 17.8 D in right eye and it was 6.04 D of hyperopia and 9.5 D of myopia in left eye. Type of amblyopia The forms of amblyopia were: iso-hyperopic (38%), refractive and strabismic (22%), iso-myopic (10%), deprivation (3%), anisometropic (3%), deprivation and strabismic (3%). Study of 15 cases with manifest deviation Mean age was 10.06 years and 54% were female. The mean of the amplitude of strabismus was 19.6 degrees. Majority (66.1%, n=10) was associated with anisometropia, while 6.67% (1) with isoametropia, 13.3% (2) with deprivation and rest 13.3% (2) were associated with both deprivation and refractive. Only 20 % (3) complained of deviation and all of them were female. Among 15 cases, 13.3% (2) noticed reduced vision after trauma and same number noticed it by closing the normal eye. Exotropia was the commonest 73% (11) and rest 27% (4) had esotropia. Study of 10 cases with deprivation amblyopia Sixty percent (6) cases were female. 20% (2) cases had bilateral cataract surgery done with PCIOL at SCEH. Eight (80%) cases had previous history of unilateral cataract and operated with PCIOL. Five (50%) had refractive associations and 30% (3) had right exotropia. Mean visual acuity was .092 (6 /62.5) in the amblyopic eye. Mean error was 2 D spherical equivalent, (-6.25 to + 6.00 D). The mean age of presentation was 2.7 years with maximum of 12 years. Study of 5 cases with hyperopic anisometropia There were no cases of myopic anisometropia. The mean age of presentation was 8 years and the mean difference between the onset and presentation was 3.40 years. Four cases (80%) were referred from eye camps. Mean error was +6.95 D. Study of 24 cases of isoametropic amblyopia Mean hyperopic error was 7.22 D and mean myopic error was - 20.25 D in right eye. Mean hyperopic error was 7.15 D and mean myopic error was -14.75 D in left eye. Mean VA were 0.182 (6/33.3) and 0.26 (6/23) in RE and LE respectively. Page 21
Profile of Amblyopia - Joshi Discussions Unlike other studies done in India and Ethiopia, the commonest type of amblyopia in our subjects was ametropic amblyopia. The mean age of the sample studied was 10.54 3.56 years. The mean age of the first presentation was 8.32 years. The critical period of the human visual system is before 8 years. It shows that the subjects with amblyopia presented too late. And the age of presentation is higher in comparison to other studies. 5, 6 Hence we can see there is lack of awareness about childhood blindness from amblyopia. The presentation was 3.4 years after the problem had started. This also suggests that a child will have to live for 3.4 years to get to the hospital service after the problem is noticed by the family and hence this obstacle should be removed for effective management of amblyopia.
SCEH Age of 1st presentation Most common Ref error 8.32 3.56 Ametropic amblyopia Hyperopia (78%) Myopia 12%
India5 7.97 6.18 Strabismic amblyopia Hyperopia (51.65%) Myopia 33.95%
Ethiopia6 6.93 Strabismic amblyopia Hyperopia 61.71% 12% myopic
References
1. 2. 3. 4. 5. 6. Duke Elder S. Ocular motility and strabismus, 1981; (6): 294-312 Noorden V. Binocular vision and ocular motility, 5th edition, Caloroso E. Clinical management of strabismus,3rd edition K. Nelson. Pediatric ophthalmology, 2nd edition Vimla Menon et al .Profile of amblyopia in a hospital referral., IJO 2005;53:227-234 Profile of amblyopia at the Pediatric Ophthalmology Clinic of Menilik II Hospital, Addis Ababa, Ethiop J Heath Dev 2008;22:201-205
Nabin Raj Joshi

Bachelor of Optometry, Final Year Institute Of Medicine Email: j_nabin@hotmail.com
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Low Vision management in children- Khadka
THE SIGHT
REVIEW ARTICLE
A short perspective on Low vision aids for children

Jyoti Khadka, PhD Student The majority of low vision children can benefit from the use of low vision aids (LVAs). Researches have found that children prefer large print for convenience over LVAs, however it is important that they are encouraged to use LVAs as there will be situations where large prints are not available and those devices may be the only options, like in shops, at a friends house, science laboratory in school, reading comics and magazines etc. There are literally hundreds of LVAs available which include a range of items that are optical, non-optical and electronic devices. The use of these devices in combination with environmental modification can highly enhance visual function in children. This article briefly outlines the different low vision devices available. Optical Devices Optical devices or aids use lenses or prisms to magnify, reduce, or otherwise change the shape or location of an image on the eye's retina. The two most common optical devices are magnifiers for seeing objects close at an arm length (known as near viewing optical devices) and telescopes for seeing objects far away (known as distance viewing optical devices). Near-Vision Optical Devices Most children with low vision can significantly improve their vision at near by employing their strong ability to focus on nearby objects (accommodation) and brining the objects of interest closer to their eyes. But those who cannot see near objects well enough need some type of near vision optical devices. These are primarily used for tasks within arm's reach, such as reading, writing, drawing etc. Examples of some of these devices are discussed here. 1. Single Vision Spectacle Magnifiers Single vision spectacle magnifiers are spectacle frame THE SIGHT, Vol. 5, Issue 5, September 2009 mounted high power magnifiers. Children often favor these devices because they do not mind the close working distances needed and the devices give a luxury with both hands free. These magnifiers provide a large field of view, and prolong viewing time with reduced eye strain. The greatest disadvantage, however is that it involves a relatively short viewing distance, which usually causes head and neck fatigue after prolong use. a) Hand Held Magnifiers These are magnifiers mounted in plastic handles. They offer flexibility in magnification at various distances between the eye and the magnifiers. Hence children can choose the most suitable and comfortable viewing distance for their activities, depending on the size of the object or the text. In addition, the availability of strong magnification power and inbuilt illumination also make these magnifiers a good choice for those children who need above average illumination. The small size hand held magnifiers that fit in a pencil case or a pocket or on a string around the neck for having a quick look at very small printed information such as on a CD cover or measurement on test tubes are particularly popular among children and young people. However, use of hand held magnifiers require steady hands and good eye and hand co-ordination, which limit usefulness of these devices to very short period near viewing tasks only. These are not the devices of choice for those with upper limb disabilities. b) Stand Magnifiers Stand magnifiers are mounted to plastic stands with legs at a fixed distance from the reading material. The availability of options like inbuilt illumination and high magnification power make them very useful for those who have profound vision loss. Some designs are useful for writing also. However stand magnifiers are comparatively more expensive and bulkier than handPage 23
Low Vision management in children- Khadka held or single vision spectacle magnifiers and they also require smooth surface to rest on. c) Dome Magnifiers Dome magnifiers are especially designed stand magnifiers. These are slightly low power large field magnifiers which are also called bright field magnifiers, which allow longer working distance and are easy to use. d) Bar Magnifiers Bar magnifiers are also especially designed bar shaped stand magnifiers with limited magnification. These are available in low powers and good for prolong reading. Distance Viewing Optical Devices Optical devices for distance viewing are also known as telescopic devices. They include handheld monoculars, clip-on monoculars, spectacle-mounted telescopes, and binoculars. These devices are primarily used for distance tasks beyond arm's reach, such as reading what is on the chalk or white board in a classroom, watching a demonstration in class, spotting street signs, viewing sports events, or watching television. However, they are bulky and not suitable for navigation. OCUTECH Vision Enhancing System: The OCUTECH Vision Enhancing System is spectacle frame mounted manual or auto focus telescope system. This kind of device makes it easier for the visually impaired to see at distance like blackboard in school, signs while travelling and changes the focus either manually or automatically at near objects like books or computer screens. Besides being bulky, the OCUTECH system is available in low magnification only, is very costly and needs battery supply for auto focus design. Electronic Magnifiers There are also some electronic magnification systems that allow the user to aim a camera at an object in the distance and then view it on a screen. Most of these devices also allow the user to view near information THE SIGHT, Vol. 5, Issue 5, September 2009 similar to the way in which video magnifiers work. In the classroom, these devices allow a child to see what the teacher is writing on the white board and then to see the book he is working from or the notes he is taking. Electronic magnifiers like CCTV, portable video magnifiers, computer with magnifying software etc. are often better accepted by children and young people than magnifiers. Non-optical Devices and Environmental Modification Optical devices when incorporated with non-optical devices and environmental modification can help a child use his or her vision more efficiently. Non-optical devices include use of controlled lighting to improve contrast. Others are sunglasses, absorptive filters preferably with side shields, hats or visors with brims for outdoor activities, reading stands to improve poor posture caused by close viewing distance. Few nonoptical devices like dark-lined papers and black felttipped pens, which produce thicker lines, make childrens own writing easier to read. Environmental modification includes placing children near windows to give them better light when reading and near the white board, painting the edge of the stairs with bright colors and provision of hand rails in school for navigation. They should also be encouraged to wear hats and caps to prevent glare especially when doing outdoor activities. It is important to remember that low vision devices do not restore or give normal vision to low vision people. They do however help to maximize their use of vision to perform certain tasks. But, some children easily incorporate prescribed optical devices into their lives, while others refuse to use them sooner or later. It is important to encourage children to use them constantly at home, school and in the community. The earlier the child is prescribed these devices, the sooner they learn to use them, incorporate devices as a part of their life styles Page 24
Low Vision management in children- Khadka and pattern of learning. Especially older children may be self-conscious and dread being different from their peers. They must be advised to weigh their needs against the drawbacks of optical devices. When children come in contact with others who question the use of devices, they may feel self-conscious. It is recommended children should be taught to respond to such questions by explaining the reason for the devices and how they function. A need for peer acceptance and conformity, particularly during adolescence is a big issue to address in order to maximize the use of LVAs. On the other hand, children usually need to be re-assessed regularly as the things they want to do change and so the advice and devices they find useful will change too. Jyoti Khadka
PhD Student School of Optometry and vision sciences Cardiff University Email: jk_goldeneye@hotmail.com
Page 25
Comparison of Induced Astigmatism after cataract surgery - Kafle
THE SIGHT
ORIGINAL ARTICLE
Induced Astigmatism in Sutureless Small-Incision Cataract Surgery using a Superior and Temporal Incision
Dinesh Kaphle BOptom., Albrecht Hennig MD, Rinki Singh MD.
Introduction: Small-incision cataract surgery (SICS) is one of the popular methods of operating cataract. Superior Incision SICS is easier and widely used technique as compared to temporal incision. Sagarmatha Choudhary Eye Hospital (SCEH), Lahan is one of the biggest eye hospitals in the world where thousands of people undergo cataract surgery each year. This study aims to compare the surgically induced astigmatism in SICS between superior and temporal approach Materials and Methods This is a comparative and analytical study and the patients with age related Cataract were selected randomly from the operation list for superior and temporal incision alternately. The patients with any preoperative pathology, complicated cataract or any known retinal pathology were excluded. Visual Acuity (VA) was taken with self-illuminated Snellens chart. Pre-operative and post-operative Keratometry was done with Hand-held Autorefractokeratometer-Nikon Retinomax. Biometry was done with Echo Scan Nidek (Model US 800). Postoperative VA and Keratometry were measured on the next day of the surgery. Astigmatism1 was recorded in minus sign considering 180 30 as with-the-rule (WTR), 90 30 as against-the-rule (ATR) and axis beyond these range as Oblique astigmatism. Induced astigmatism was calculated by taking difference between Post-op astigmatism and pre-op astigmatism. Frown Incision of 5-6mm was made with blade from 10 to 2 oclock and 2 to 5 oclock for superior and temporal incision group respectively. Sclerocorneal tunnel was made with crescent knife and keratome of 3.2 mm THE SIGHT, Vol. 5, Issue 5, September 2009
(superiorly and temporally). Endocapsular technique was used. Nuclear extraction was done with fishhook. PMMA lens of 5.5mm was inserted. Results: Out of 100 subjects, 50 (25 male and female each) underwent superior incision and 50 (26 male and 24 female) underwent temporal incision. Majority of cases were from 51-60 years age group in both the methods. In both groups more than 90% of patients were Functionally Blind2 before cataract surgery. Almost 80% gained normal VA after surgery. The visual outcome was slightly better in superior incision as compared to the temporal incision. Induced Astigmatism The induced astigmatism was much higher (almost five times) in superior group as compared to the temporal Induced Astigmatism Mean Induced Astigmatism (Dcyl) Mean Axis (deg.) group. Shift of Astigmatism Superior Incision 0.27 Temporal Incision 0.06
113.0
98.44
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Comparison of Induced Astigmatism after cataract surgery - Kafle Pre-operatively, majority of patients had oblique astigmatism and against-the-rule astigmatism in superior and temporal group respectively. Post-operatively, the shift of astigmatism was towards WTR in temporal group and towards ATR in superior group, whereas the number of patients with oblique astigmatism was decreased in both the groups. Two cases had no astigmatism on post-operative refraction on temporal incision group. Discussion: The mean induced astigmatism was 0.27 DC x 113 for superior group and 0.06 DC x 98 for temporal group. The amount of astigmatism found was less as compared to the study3 by Gorkhale Nikhil S. and Sawhney Saurabh. Still the pattern of induced astigmatism was same in both studies i.e. induced astigmatism less in temporal group than superior group. The post-op astigmatism was measured in the next day of the surgery as the follow-up rate of the patiens was poor. Induced astigmatism was calculated by simple method unlike vector analysis method used by Gorkhale Nikhil S. and Sawhney Saurabh because of the unavailability of proper resources for the analysis. There was shift of astigmatism towards ATR in superior group and towards the WTR in temporal group. This is similar to the findings of Goes F M Jr, and Goes F J study4 where they had analyzed the results by using Cravy-Jaffle-and Naeser-method.
Pre-operative Astigmatism Post-operative Astigmatism
Type of Superior Temporal Superior Temporal astigmatism Incision (%) Incision (%) Incision (%) Incision (%) WTR (180 30) ATR (90 30) Oblique 10 (20) 6 (12) 11 (22) 12 (24)
12 (24)
25 (50)
18 (36)
23 (46)
28 (56)
19 (38)
21 (42)
14 (28)
Conclusion: Surgically induced astigmatism is lower in temporal incision as compared to superior incision. Postoperatively, the shift of astigmatism was towards WTR in temporal incision and towards ATR in superior incision. References:
1. 2. Grosvenor Theodore, Primary Care Optometry, 3 rd ed., USA, Butterworth-Heinemann Khurana AK. Ophthalmology, 3rd ed. New Age Intrnl.;2003,p-424 (Category of Visual Impairment; WHO 1977) Gorkhale Nikhil S.,Sawhery Saurabh.Reduction in astigmatism in manual small incision cataract surgery through change of incision site. Journal of Gorkhale Eye Hospital and Eye Bank.2005;53(3) Goes FM Jr, Goes F J. Astigmatic changes after smallincision cataract surgery using superior or temporal corneal incision. Bull Soc Belge Ophthalmol. 1998;268:27-32
3.
4.
Dinesh Kaphle, B.Optom.

Consultant Optometrist Visioncare, Blantyre Adventist Hospital, Blantyre, Malawi, Africa E-mail: Kaphledinesh@hotmail.com
Page 27
Pediatric Visual Impairment- Dev
THE SIGHT
REVIEW ARTICLE
Pediatric Visual Impairment

Mahesh Kumar Dev
Introduction Visual impairment occurs when any part of the visual system is defective, diseased or malfunctioning. The primary causes of vision impairment in children are refractive error, congenital cataract, corneal scarring, congenital glaucoma, retinopathy of prematurity (ROP) etc. Corneal scarring due to Vitamin A deficiency, measles infection, ophthalmia neonatorum and the effect of harmful traditional medicine are the leading causes of blindness in the developing countries (Gilbert and Fester 2001). Other causes include albinism, optic atrophy, microphthalmos, aniridia etc. Prevalence and Magnitude Prevalence, magnitude and causes of blindness in children are largely determined by level of socioeconomic development and health care provision. Visual impairment in children is more common in poor countries due to inadequate eye care services. WHO estimates 1.4 million children are blind throughout the world, 1 million of whom live in Asia. The prevalence ranges from 0.3/1000 children aged 015 years in affluent countries to 1.5/1000 children in very poor communities. Every minute a child in the world goes blind (WHO-2006). Based on data from 2002 Survey of Income and Program Participation, 189,000 children of 6 -14 years of age have difficulty seeing words and letters in ordinary newspaper print even after wearing glasses or contact lens. Four percent of children under 14 years of age are blind worldwide (Thylefors et. al). Although the prevalence of visual impairment is relatively lower in children than in adults, the number of blind years (number blind length of life) in children is much greater than that in adults. They have a lifetime of blindness ahead, with an estimated 75 million blindyears. About 40% of the causes of childhood blindness are preventable or treatable. The control of childhood THE SIGHT, Vol. 5, Issue 5, September 2009 blindness is a priority of WHO/IAPB Vision 2020: The Right to Sight. Vision 2020 Priorities Corneal scarring due to Vitamin A deficiency, measles infection, ophthalmia neonatorum and the effect of harmful traditional eye medicines are given priorities in poor and very poor region. Refractive error: Treatable cause in all regions. Cataract and glaucoma: Important treatable causes in all regions. ROP: Preventable and treatable. It is important in middle income countries and urban centers in developing countries. Low Vision: Service need to be expanded or developed in all regions. Impact of Visual Impairment Visual impairment in childhood has an impact on the childs development, education and care given by families and professionals. These influence profoundly childs employment, social prospects and opportunities throughout the life. Impaired vision can affect a childs emotional, neurological and physical development by potentially limiting the range of experiences and the aids of information a child is exposed to. Nearly 2/3 of children with visual impairment have one or more developmental disabilities such as mental retardation, cerebral palsy, hearing impairment, epilepsy etc. So, children with vision impairment very often need services such as special education program to assist in their development. Role of Eye Care Professionals To provide specialist pediatric eye care, combining optical, medical and surgical management of specific disorders. To contribute to multidisciplinary visual impairment teams ideally combining medical, educational and social service professionals to Page 28
Pediatric Visual Impairment- Dev ensure comprehensive and coordinated care of all visually impaired children and their families. To contribute to specific assessment of special educational needs and certification of eligibility for special service. To contribute to monitoring visual impairment in geographically defined population they serve. as perinatal care. The current and future directions in research for diagnosing and treating pediatric vision disorders emphasize several areas. They include amblyopia, refractive screening, intraocular lens (IOL) implant, retinoblastoma, genetics including gene identification and mapping. Low vision due to congenital cataract is decreasing owing to decrease in incidence rate and increasingly successful use of IOL implant in younger children. The use of IOL in unilateral cataract decreases the severity of amblyopia. The advances in cytogenetics have greatly increased the ability to detect and potentially prevent genetic eye diseases. Genetic counseling also helps in decreasing the incidence of such diseases.
Conclusion Because of the wide range of causes of childhood blindness, intervention must be disease-specific and directed at more than one level of the eye-care delivery system. Preventive measures include the distribution of vitamin A capsules, immunization and prenatal as well References
1. 2. 3. 4.
Taylor David, Hoyt S. Creig, editors. Pediatric Ophthalmology and Strabismus,3 rd edition. J Comm. Eye Health 2001; 14(40): 53-56 Silverstone Barbara, Lang A. Mary, Rosenthal P. Bruce, Faye E.Eleonar. The Lighthouse Handbook on Vision Impairment and Vision Rehabilitation, Volume1.Vision Rehabilitation Oxford University Press;2000. Gilbert C E, Foster A. Childhood blindness in the context of Vision 2020: The Right to Sight. Bull WHO 2001; 79:227-232.
Mahesh Kumar Dev

B. Optometry, IX Batch IOM, Maharajgunj
Email: maheshdev2002@yahoo.com
Page 29
Progressive Addition Lenses - Paudel
THE SIGHT
REVIEW ARTICLE
Progressive addition lenses: What neophyte wearers and practitioners must know???
Nabin Paudel, BOptom
Presbyopia reflects a clinically significant loss of amplitude of accommodation, or an inability of eye to focus on objects at near. Presbyopia is a physiological condition and occurs after 40 years of age in most of the individuals. The exact mechanism of presbyopia is still under investigation but various researches have found that it is due to the aging process of lens capsule, tendons and ciliary muscles. The provision of extra plus power by external means is the only solution of this problem, which may be in the form of spectacles or contact lenses. Though, the practice of surgery for correction of presbyopia is also under investigation, spectacles are the best and the easiest method of correction of presbyopia. Presbyopic corrections in spectacles can be given in various ways. Single vision lenses: These glasses are worn only for near works and should be taken off otherwise. They allow clear vision only for near. Multifocal lenses: They incorporate power for near as well as distance and can be used all the time. They provide clear vision for near as well as distance. Progressive addition lenses: Progressive addition lenses (PALs) are the current state-of-art advances in multifocal lenses. PALs are especially designed lenses which incorporate correction for all distances ranging from distance to near. These lenses have a wide zone for distance in the upper part of the lens and a relatively wider near zone in the lower part of the lens which is connected by a narrow progressive zone. In the progressive zone the power gradually goes on increasing. So, these lenses are called progressive addition lenses. In the course of making a progression zone, on either side of the zone certain amount of astigmatism is produced which is practically unavoidable. Various researches have been done and are currently under investigation in order to minimize the THE SIGHT, Vol.5, Issue 5, September 2009 peripheral aberrations / astigmatisms so that they least interfere with useful field of vision. The schematic diagram of PAL is shown in figure 1. Progressive addition lenses have various advantages over single vision or bifocal spectacles. The absence of demarcation line between distance and near zone is the greatest advantage. PALs provide clear vision for all distances in contrast to single vision lenses and bifocal lenses. PALs dont cause image jump (areas appearing slanting and bumpy) while the eyes are shifted from distance to near or vice versa. However, PALs have certain disadvantages as well. They cause distortion of the peripheral vision, they are costly and they need certain time for adaption. However, the use of PALs is not as easy as we think. It is not as simple as wearing a single vision lens or other traditional lenses. One cannot guarantee the success of PAL wear in any patient. The successful wear of a PAL depends upon various factors. The most important factor is patient selection. Most patients adapt to PALs very well but PALs are not for every presbyope who walks through the door. PALs are not recommended to the patients who are satisfied with their current multifocals, who have no interest in cosmesis and who have previous unsuccessful PAL wear. The ideal candidates for PAL wear are: Emerging presbyopes (these patients are usually interested in avoiding segment lines and due to the minimal add power requirements for them, Page 30
Progressive Addition Lenses - Paudel distortion is minimal and adaptation is fairly easy) Previous PAL wearers (easy to adapt) Individual highly motivated to use progressives and have realistic expectations about their vision with new spectacles. There are some individuals for whom special considerations should be taken before prescribing PALs. Those individuals include: Presbyopes with high addition (> +3.00D) Previous wide segment bifocal users Individuals sensitive to vertigo or motion sickness Individuals having large oculomotor imbalances Individuals particularly sensitive to change in vision However, the ability of a qualified eye care professional to determine refractive error precisely and to evaluate various factors like frame selection, frame adjustment, taking measurements and patients occupation also play very important role in the success of PAL wear. So, it is strongly recommended for one to visit a qualified optometrist if he/she is really interested in PAL wear. Various designs of PALs are available in the optical market which suit for different patients according to their daily needs. It has been only few years that PALs were introduced in Nepal. There are various companies which produce PALs e.g Essilor, Hoya, Shamir, Seiko etc. Most of the lenses that are used in Nepal are from Essilor. So, prescribing progressives is no small deal. It may lead a patient dissatisfaction and cut the number of patients for a private practitioner if not properly taken care of, but if precautions are taken earlier, patients will love the practitioner. For the neophyte PAL wearers, it is better they have realistic expectations about their vision and be motivated so that they can enjoy the benefits of PAL life long. References:
David R. Pope. Progressive Addition Lenses: History, Design, Wearer Satisfaction and Trends. Vision Science and Its Applications, OSA TOPS Vol. 35, 2000 Darryl J Meister, ABOM. Progressive lens dispensing. Clifford W. Brooks and Irvin Borish. System for Ophthalmic Dispensing, 3rd Edition.2007 T. E. Fannin and T. Grosvenor, "Clinical Optics," 2nd Edition. Butterworth-Heinemann, Boston, 1996 C. Fowler, "Recent trends in progressive power lenses," Ophthal. Physiol. Opt. 18 234-2371998
Nabin Paudel
Consultant Optometrist Sudristi Eye Clinic, Kathmandu Email: paudel.nabin@gmail.com
THE SIGHT, Vol.5, Issue 5, September 2009
Page 31
Ocular Malingering: Adhikary
THE SIGHT
Volume 5, Issue 5
ORIGINAL ARTICLE
Profile of binocular visual status of paediatric patients presenting with complaints of asthenopia
Fathimath Nestha Mohamed, Dipesh Bhattarai
Abstract
Aim: To determine the refractive status, vergence status, accommodative amplitude and fusional vergence status of paediatric patients presenting with symptoms of asthenopia. Methods: Total of 41 patients presenting with complaints of asthenopia were enrolled from Pediatric Department, Sagarmatha Choudhary Eye Hospital (SCEH). VA assessment, Slit-lamp examination, Retinoscopy and Binocular vision assessment were done. Results: Most common age group presenting with symptoms of asthenopia in this OPD was found to be 13 15 yrs among male and female. Presentation of male (51%) and female (49%) were almost similar. The most common presenting complaint was headache with eyeball pain. The most common forms of refractive errors were simple hyperopic astigmatism and simple hyperopia. The most common binocular disorders found were fusional insufficiency, and combination of fusional and convergence insufficiency. Conclusion: Asthenopia was found to be related to deficiency of fusional vergence system, insufficiency of accommodation, vergence dysfunction and refractive error. And 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 children overall academic and physical development.
Key words: asthenopia, accommodation, convergence, fusional insufficiency
Introduction: Asthenopia describes the different symptoms such as pain, blurred vision, diplopia and headache. Asthenopia is generally of two types, mainly refractive usually due to refractive errors and anisometropia and muscular asthenopia which may be due to convergence, accommodative insufficiency and heterotropia/ heterophoria. Children with asthenopia complain of such symptoms usually while reading or writing. Amongst 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 years of age (Sterner et all 2006). Page 32
This study aims to determine the refractive and binocular visual status of paediatric population presenting to paediatric OPD of SCEH with complaints / symptoms of asthenopia.
Methods and methodology: This is a descriptive and hospital based study. Children of age group 5 to 15 yrs presenting with symptoms of asthenopia with a presenting unaided visual acuity of each eye 6/6- 6/9. Patients with any ocular or systemic pathology were excluded from the study. General ocular and medical history was taken. Uncorrected visual acuity for distance was taken with Snellens chart at 6m. A complete ophthalmologic evaluation was done. Binocular vision was assessed by means of cover test for near and distance at 40 cm and 6m respectively. Positive prism fusion range was measured with Base out prism at near and distance at 40 cm and 6m respectively. Normal range for near was considered as 9/19/10 (blur/ break/ recovery) and 17/21/11 (blur/ break/ recovery) for distance. Prism cover test was used to assess the amount of deviation. Exophoria was defined as 4 prism dioptres at distance and 6 prism dioptres at near. Esophoria was defined as 2 prism dioptres at distance and 4 prism dioptres at near. Near point of convergence was measured with RAF rule. Normal range was set at 6-9cm. Near point of 12 cm was denoted mild convergence insufficiency, 13-18 cm as moderate insufficiency and19 cm and more as marked convergence insufficiency. Near point of accommodation was measured with RAF rule with N6 target. To be ruled out as accommodative insufficiency, the patient had to have near point of accommodation worse than 100/(16-(age/4)) on RAF rule, Retinoscopy was done at a distance of 6 meters followed by subjective refraction. Dynamic retinoscopy and cyclorefraction was done whenever required.
14 11 8
Results: Among the total of 658 patients who presented to the OPD, 41 (6.23%) patients presented with symptoms of asthenopia. Presentation of male (51%) was almost similar to that of female (49%). Most common age
10 9
10
Fig. 2 Pattern of vergence and accommodative function
group presenting with symptoms of asthenopia was 13 15 years among male and female both. The most frequent presenting THE SIGHT, Vol. 5, Issue 5, September 2009
Page 33
Figure 1: Pattern of refractive error
Ocular Malingering: Adhikary complaint was headache plus eyeball pain (34%), followed by headache only (20%) and headache, eye ache plus watering (17%). The most common refractive errors were simple hyperopia and simple hyperopic astigmatism, 24% each (Fig 1). Thirty out of 41 patients required refractive correction and glasses were prescribed. On binocular vision assessment, 81% were found to have orthophoria while 15% were exophoric. Fusional insufficiency was found in 34% and convergence and fusional insufficiency in 20%. (Fig 2). For patients having convergence insufficiency and fusional insufficiency, pencil push up exercise and fusional exercise as home therapy was given for one month along with refractive correction. And for patients with accommodative insufficiency, Hart chart rock exercise was prescribed as home therapy. Discussion: Since this study has not been analytical, we cannot conclude the relation between symptoms of asthenopia with orthoptic parameters such as accommodative, convergence, fusional insufficiency, latent strabismus and refractive errors. But 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 children overall academic and physical development even though the child may have normal vision. Conclusion: The prevalence of asthenopia was 6.23% of the total population presenting to the pediatric OPD. Asthenopia was found to be related to deficiency of fusional vergence system, insufficiency of accommodation, vergence dysfunction and refractive error. References:
1. 2. 3. 4. Is all asthenopia the same? JAMES E. SHEEDY, OD, PhD, FAAO, JOHN HAYES, PhD, and JON ENGLE, BS , VOL. 80, NO. 11, PP. 732739, OPTOMETRY AND VISION SCIENCE Prevalence of chief complaints in a pediatric clinic population. Graham B. Erickson,OD,FAAO,Dibra L. Kirk,OD, and Frances D. Guerrero,OD,Vol.76, No.2, PP 88-93, OPTOMETRY AND VISUAL SCIENCE. Asthenopia in school children, Saber Abdi , Section of ophthalmology and vision department of clinical neuroscience, St. Eric Eye Hospital, Karolinska institute, Stockholm, Sweden. Frequency of convergence insufficiency among fifth and sixth graders, Michael W. Rouse, OD, MSEd, FAAO, Eric Borsting,OD, MS, FAAO, Leslie Hyman, PhD, Mohamed Hussien,PhD, Susan A. Cotter, OD, FAAO, Mary Flynn, OD, Mitchell Scheiman, OD, FAAO, Michael Gllaway, OD, FAAO, Paul N. De Land, PhD, and CIRS Group. Vol.76. NO.9.PP.643-649, OPTOMETRY AND VISION SCIENCE Frequency of convergence insufficiency in optometry clinic settings, Michael W. Rouse, OD, OD, MSEd, Leslie Hyman, PhD, Mohamed Hussien,PhD, Harold Solan, OD, MA and CIRS Group, , Leslie Hyman, PhD, Mohamed Hussien,PhD, Vol.75, NO.2, PP.88-96. OPTOMETRY AND VISUAL SCIENCE. Prevalence of General Dysfunctions in Binocular Vision, Robert Montes-Mico, DO. ANN OPHTHALMOL.2001;33(3):205-208
5.
6.
Fathimath Nestha Mohamed and Dipesh Bhattarai

Bacelor of Optometry, VIII Batch Maharajgunj Campus (IOM) Email: nesthu@gmail.com, dipeshbhattarai@hotmail.com
THE SIGHT
Volume 5, Issue 5 September, 2009 THE SIGHT, Vol. 5, Issue 5, September 2009
REVIEW ARTICLE
Page 34
Ocular Malingering: Diagnosis and Management

Rabindra Adhikary
Introduction Optometrists frequently find themselves in situations in which they have to determine whether patients' visual signs and symptoms are legitimate or feigned. Psychogenic visual impairment or ocular malingering creates an immense challenge to a clinician. The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV TR) defines malingering as "the intentional production of false or grossly exaggerated physical or psychological symptoms, motivated by external incentives such as avoiding military duty, avoiding work, obtaining financial compensation, evading criminal prosecution, or obtaining drugs 1, 5. Legally, it is often referred to as fabricated mental illness or feigned mental illness 2. It is difficult to predict as to which type of malingering is called the ocular. Ocular malingering may be in many forms like unilateral or bilateral total visual loss, visual field loss, diplopia, night vision defects, color vision defects, ocular muscle defects, and automutilatory defects, blepharospasm and asthenopia etc.3 Timely diagnosis of a case of malingering would prevent one from expensive medical testing like neuroimaging. Regardless of the underlying cause, the primary concern of the eye care practitioner is to demonstrate visual potential better than suggested by the patient's subjective reports.4 By understanding the types, motivations, and presentations of malingering, a clinician can systematically and empathetically diagnose and respond to the intentional feigning of psychiatric symptoms. Hysteria is similar to malingering except that it is unconscious.6 Children failing the Snellens test and showing no improvement in visual acuity could, in fact, be malingerers. Retinoscopy, with cycloplegia, is the best method to determine if a refractive condition exists.7 DSM states that malingering is suspected if any combinations of the following are observed8 1. Medico-legal context of presentation THE SIGHT, Vol. 5, Issue 5, September 2009 Page 35 2. Marked discrepancy between the persons claimed stress of disability and the objective findings 3. Lack of cooperation during the diagnostic evaluation and in complying with prescribed treatment regimen 4. The presence of Antisocial Personality Disorder Types of Malingering9 Positive Malingering: practiced by the same type of person with same objects in view and will. o Simulation: feigning of a non-existent disease or disability o Exaggeration or aggravation: pretence that the condition is worse than it is o False attribution: assignment of unreal disease or injury Negative Malingering: o Dissimulation: pretence that a disease or disability does not exist or it has less severe effects than it really has. Diagnostic Tools for Ocular Malingering 1. Pupillary Reflexes If direct and consensual reflexes are within normal, lower visual paths including efferent paths should be intact. When this test is taken at pitch dark room with strong focal illuminator, malingerer abruptly squeezes eyes. Patients orientation and mobility to the environment also accounts for his visual condition. 2. Trial Frame Method One easy way of detecting malingering is to keep new prescription lenses on the trial frame which are usually of low power (within 0.50Ds). The other way is simply going on reducing the fog before each eye starting from +3.00Ds and at the same time encouraging the patient to read out the letters saying, this should make you see really very clear. (Tory Moore, OD). In Harlans test +10.0 Ds convex lens is kept before good eye
Ocular Malingering: Adhikary and patient is asked to read, if he succeeds than alleged blind eye should be normal.10 Visual Field Method When one presents with unilateral total blindness, plotting the visual field may give a clue to rule out the malingering. The so called blind eye is not covered while testing the visual field. The result will show there will be no blind spot of the good eye: as it has been compensated by the other eye that was supposed to be blind. (Larry J. Greidinger O.D.*) Red Green Glass Method The patient is given with the red green glasses to wear and asked to read the letters at the bottom of the vision chart. S/he will read all the letters FRIEND, DOG etc. In case of claimed unilateral blindness, there should be no stereopsis present on testing with Polaroid glasses. (Merill Bowan, OD*) Vertical Prism Method The patient will complain of diplopia on placing a vertical prism of 6 prism dipoter BD/BU over the good eye if it is a case of malingering, applicable to rule out malingering from unilateral blindness. (Richard Jackson, O.D.*) Objective Refraction Method Correlating the refractive error from objective finding with the uncorrected visual acuity and subjective refraction also gives a cue. (Alan Rod, OD*) Pattern VEP Method11 The objective visual acuity estimated by PVEP will be greater than the subjective one. Schmidt-Rimplers Test Patient is asked to look at his hands and touch 2 index fingers, a true blind executes easily but a feigner ends up embarrassed. Burghardt 's test is its modification10 Preferential Acuity Test/Cat Ford Drum Test It is generally useful for infants whereby suspected infant malingerer follows the striped patterns involuntarily presented before the eye. Menace reflex test When an object is fiercely approximated towards eyes of suspected total blind, he should not close his eyes at any cost if he is true blind. Reverse Purkinje Phenomenon13 As we know Purkinje phenomenon is reversed in essential nyctalopia, so patient who complain of night blindness with no accountable organic reason should pass this test. Patient is asked to view blue and red disc at the same time and the intensity of illumination is gradually decreased. Normally red becomes more rapidly black than blue (reverse is the case for a night blind), hence simulator will say the normal response or that both disc disappear at once. 12. Vieusse test10 On a plain stereoscopic card are placed two wafers of different colors, one red for instance, and the other blue, at a distance in the case of each wafer of cm. from a vertical line dividing the card in halves. When so small a distance separates the wafers, viz 1 cm, the wafer on the right side of the card appears to be on the left, and the wafer which is on the left side of the card appears to be on the right. The card is placed in a stereoscope, and the person requested to look at the card through the instrument. If he admits that he sees both wafers, then of course he is seeing with both eyes. Bar reading is somewhat similar binocular test.12 13. Detecting bilateral amblyopia14 It is always ground for suspicion when the person in reading aloud the test type, declares that he can read no further, although, thus far, he has made no mistake in identifying all the letters. A truly honest reader will almost invariably miscall the most difficult letters (for instance B or S) in one line, before declaring his inability to read any of the letters of the next. Again, if he miscalls only certain letters in a line and these are the easiest letters in that line (for instance T and L), this is ground for some suspicion. The list is simply endless. Management There should be a detail family history, socio-economic information and every knowhow of psychological aspect before we reach to the management.15 It is because most of the time malingerers attend hospital seeking special attention and financial benefit. So first of all the cause of cheating and pretence should be pried out meticulously knowing history and family background. Also, a thorough clinical examination leads to the diagnosis. Evaluation must include auxiliary ophthalmologic Page 36
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Ocular Malingering: Adhikary testing, neuro-imaging of the visual pathway, review of the medical history and lifestyle, and psychiatric evaluation. Co-management with a psychiatrist is essential for patients with functional vision loss.16 A References:
1. 2. R. Rogers. Clinical Assessment of Malingering and Deception 3rd Edition, Guilford, 2008. Behavior of the Defendant in a Competency-to-Stand-Trial Evaluation Becomes an Issue in Sentencing - Fabricating Mental Illness in a Competency-to-Stand-Trial Evaluation Used to Enhance Sentencing Level After a Guilty Plea". Journal of the American Academy of Psychiatry and the Law. http://www.jaapl.org/cgi/content/full. Retrieved on 2007-10-11. M Fahle and G Mohn. Assessment of visual function in suspected ocular malingering. Br J Ophthalmol. 1989 August; 73(8): 651654. Raghunandan A, O.D., Ph.D., M.S., B.Optom. and Buckingham RS. O.D. The utility of clinical electrophysiology in a case of nonorganic vision loss. aMichigan College of Optometry, Ferris State University, Big Rapids, Michigan. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revision. Washington, DC: American Psychiatric Association; 2000. A review of ocular malingering and hysteria for the flight surgeon Aviation Space Environtal Med. 1983 Oct; 54(10):934-6. Dandona R, Dandona L. Refractive error blindness. Bull WHO 2001; 79(3): 237-243 DSM-IV-TR, American Psychiatric Association, 2000. Halligan, P.W., Bass, C., & Oakley, D.A. (Eds.) (2003). Malingering and Illness Deception. Oxford University Press, UK.
malingering assessment must be comprehensive, including a thorough clinical interview, a review of all records, examination of collateral information, and psychological testing when available.17
9. Jones and Llewellyn, malingering, Phila. 1917 10. A. G. Mcauley, MD. The ocular malingerer. Canadian Med Assoc J, ophthalmnological department, royal victoria hospital, Montreal 11. Nakamura A,MD, Akio T, MD, Matsuda E, et al. Pattern Visual Evoked Potentials in Malingering,. Journal of Neuro-Ophthalmol. 2001; 21(1): 4245. 12. Graf M H., MD; Jens Roesen. A Surprising Visual Acuity Test. Arch Ophthalmol. 2002;120:756-760. 13. Spaeth, E. B. The Differentiation of the Ocular Manifestations of Hysteria and of Ocular Malingering. Clinical Medicine. Behavioral & Social Sciences. 14. Ocular malingering and hysteria: diagnosis and management, 1979 Sep-Oct; 24(2):89-96. 15. Charles A. Layton, Jr., O.D. Perry W. Bailey, M.D. Refractive Problems in Malingering And Hysterical Amblyopia, The Aust J Optom. 1953 sept; 30. 16. Rex B. Villegas O.D and Pauline F. Ilsen O.D Functional vision loss: A diagnosis of exclusion. J American Optom Assoc. October 2007; 78 (10): 523-533. 17. Dr Garriga. Malingering in the Clinical Setting. Psychiatric Times. March. 1, 2007; 24 (3). *Extracted from the informal communication from different websites.
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Rabindra Adhikary
Bachelor of Optometry Maharajgunj Campus (IOM) Email: ravinems@gmail.com
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Primary Eye Care - Paudel
THE SIGHT
REVIEW ARTICLE
Primary eye care: Our achievements and future strategies

Prakash Paudel, B.Sc., BOptom., FIACLE, FLVC
Introduction Primary eye care (PEC) is the provision of appropriate, accessible and affordable care that meets patients' eye care needs in a comprehensive and competent manner1. PEC provides an entry point for patients to receive refractions and glasses or contact lenses, screenings for asymptomatic eye diseases, diagnosis and treatment of most eye conditions, referral to specialists, and coordination with other aspects of medical care1. The attributes of primary care are first contact, accessibility, continuity, longitudinality, comprehensiveness, coordination, equity, and accountability2. PEC needs to be supported and sustained by an adequate referral system. As PEC is one of the essential components of primary health care (PHC), it should be available to individuals and families wherever they live and whatever their socio-economic condition is3. PEC worker should be able to manage common ocular conditions, diagnose blinding conditions, make appropriate referral, explain the possible interventions and help the patient in decision making, encouraging active involvement of the individual and the family.
Concepts of Primary Eye Care3 (Modified in current context) Eye Diseases Trachoma Vitamin A deficiency (Focal diseases; Starts in childhood) Cataract Glaucoma Diabetic retinopathy Refractive Error* Presbyopia (Affect any age but mainly adults; Occur everywhere) Acute red eye Ocular emergencies (Affect any age; Occur everywhere) Activity Primary preventionIn the community through PHC Secondary preventionIdentify and treat in the community Identify and refer for treatment Who can be Involved Teachers/ Community Leaders Traditional Birth Attendants/ Healers Primary Health Care Workers Community Based Rehabilitation Workers General Physicians Community Based Rehabilitation Workers Primary health Care Workers Ophthalmic assistants* Optometrists* General Physicians
Diagnose and Treat Or Diagnose and Refer
Primary Health Care Workers Ophthalmic assistants Optometrists General Physicians
*only PEC is related to the elements of primary health care but its development in a region or country depends upon the existing health care services and availability of different categories of health workers. The supply of clean water and sanitation, effective maternal / child care and immunization system, availability of nutritious food at affordable costs, the availability of secondary health/eye care to look after referred cases and provision of essential drugs are key PHC elements which help in addressing issues such as trachoma and vitamin A deficiency.
Primary Eye Care is Related to the Elements of Primary Health Care3 (Safe) Water Basic Sanitation Prevention of trachoma and vitamin A deficiency: prevention of diarrhoea which may reduce cataract prevalence Prevention of trachoma and vitamin A deficiency
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Ocular Prosthesis - Raizada

Maternal/ Child care; family planning Immunization Control of locally endemic diseases Treatment for common diseases Provision of essential drugs Prevention of vitamin A deficiency, measles, trachoma and ophthalmia neonatrum Prevention of childhood blindness from measles and congenital rubella Trachoma control Corneal ulcers, refractive errors, trauma Tetracycline eye ointment and vitamin A capsules
The target of PEC services should be sufficiently comprehensive to cover all aspects of services targeted for all community people whether they have problems or not. The WHO guidelines for PHC have indicated PEC practitioner the level of work which they have to take care of with appropriate management steps.
WHO GUIDELINES FOR PRIMARY EYE CARE4 Conditions to be recognized and treated by a trained primary health care worker Ocular Diseases / conditions Conjunctivitis and lid infections Acute conjunctivitis Ophthalmia neonatorum Trachoma Allergic and irritative conjunctivitis Lid lesionse.g. stye and chalazion Trauma Sub-conjunctival haemorrhages Superficial foreign body Blunt trauma Blinding malnutrition Corneal ulcers Lacerating or perforating injuries of the eyeball Lid lacerations Entropion/trichiasis Burns: chemical, thermal Painful red eye with visual loss Cataract Pterygium Visual loss <6/18 in either eye
Conditions to be recognised and referred after treatment has been Initiated
Conditions that should be recognized and referred for treatment
The integration of PEC in the PHC is the most emphasized concept but it is mostly being neglected by many countries. The PEC is not practiced at primary level in many developing nations because of deficient or untrained human resources and ineffective governmental policy. However, PEC is implemented as a separate program under the aegis of NGOs which is not readily approachable and affordable to all the community who are in immense need of care. Such PEC is limited conducting an annual screening and outreach activities in the remote or developing communities. Since major causes of blindness in developing countries are either preventable e.g. trachoma, Vitamin A deficiency etc. or curable, such as cataract, priorities should be given to identification and appropriate management or referral of such cases at the community level. However, without effective service delivery approaches at the community level, magnitude and consequences of such diseases can not be minimized. The establishment of PEC centers or visual centers is crucial in achieving the objective. For the PEC program to be successful it must have close link with secondary and tertiary levels of health care and a suitable and sufficient back-up referral system. This kind of arrangement lacks in most countries hence requiring an adoption of appropriate eye care delivery model for such provision. Nepal has effectively worked in development of PEC; however it further needs good plan of action for the equity, excellence and efficient services. Past development PEC was given major importance in health delivery system since ophthalmic assistants (OAs) training started following the National Blindness Survey in 1981 which identified blindness as a major public health problem. These trained personnels are capable in assisting ophthalmologists in clinical and surgical procedures in secondary and tertiary hospitals and also to deliver PEC services independently in rural communities/ PEC centres 5. They were the backbone for the national program for the prevention and control of blindness in rural areas when ophthalmologists number was limited. THE SIGHT, Vol. 5, Issue 5, September 2009 Page 39
Ocular Prosthesis - Raizada There were 15 ophthalmologists in 1980 which dramatically increased to 45 by the year 1989 6. Nepal Netra Jyoti Sangh (NNJS) served dominantly providing the services in rural districts establishing PEC centers and recruiting a trained OAs to look after the PEC including refraction services. The objectives of PEC services delivery were in some extent fulfilled by the existence of these services. Vitamin A deficiency was found to be responsible for one-third of acquired bilateral blindness in preschool children in 1981 survey7. After integrating Vitamin A capsule distribution in National Immunization program, minimizing vitamin A deficiency has been possible. Similar effective results were observed in trachoma control program launched at several districts; as a result of which trachoma has disappeared from western Nepal 8. These programs were successful only because of their integration with PHC and utilization of primary health workers. Another success story for the delivery of primary eye care services were frequently organized eye screening and surgical camps by hospitals, institutes, NGOs and organizations. More than two-third population in geographically inaccessible area was dependent to such services in past years. The ophthalmology training started in late 80s and optometry in late 90s have further expanded the secondary and tertiary services mainly to major cities and towns predominantly near Indian border. The hospitals nearest to the rural centers started getting referred patients. The easy access to eye care service ultimately generated public interest in receiving the services. These interventions have established the eye health delivery system of Nepal to be one of the best in South East Asia. However, there are lots of issues to be improved in many areas. Present Situation Currently, there are 21 eye hospitals, about 20 eye units in general hospitals and medical college hospitals, around a dozen of eye health /satellite centers and 59 PEC centers supported by NNJS and Tilganga with partner organizations 9. Beside these, private nursing homes and hospitals are also providing eye care services. There are also mushrooming optical shops in every corner of towns/cities with limited refraction services and spectacles dispensing facilities. However, there are still a dozen districts where no eye care services exist in any form. In hilly districts, available services are unapproachable due to barriers to access the services because of geographical, financial, gender, environmental and motivational factors. Since every developmental region has at least one eye hospital, the service has been regionally taken care by these hospitals. The frequency of free eye camps and screening camps is less than previous years. Some medical camps organized by national/overseas organizations also seek help from near by health facilities. 10 Some centers also organize a surgical camp with the help of major hospitals once in a year to operate those who cant afford the cost for surgery. Though the PEC services are mostly given priority to the remote and rural communities, eye institutions and NGOs are also giving importance to PEC in urban areas organizing screening camps, awareness programs and school screening. There are still about 40-60% children in remote Nepal who have never visited PEC centers or hospitals. There have been tremendous efforts from every corner by ophthalmic fraternity to bring up the eye care situation in current stage. The trainings for ophthalmic assistant, ophthalmologist and optometrist have uplifted the shortage of human resource in some extent though there is long way to achieve the target aimed by Vision 2020: The Right to Sight. Though it is for few days in a week, some hospitals recruit ophthalmologists to do cataract surgeries in satellite clinics, the days have come for ophthalmologists and optometrists to involve in PEC more strongly. Future strategies As mentioned earlier, PEC needs to be integrated into PHC for better service. For this purpose, primary health practitioners should be trained in basic PEC. To solve the problem of uncorrected refractive error, it is important to provide comprehensive services, both refraction and dispensing of spectacles, at the PEC level.11 OAs should be capable of doing refraction and dispensing services in every PEC centers. The quality and service monitoring and evaluation are very essential components in the system. The mushrooming optical shops should be allied in the system providing registration and regular monitoring. Unless these are organized, the quality provision in dispensing of spectacles can rarely be expected. The monitoring and skills upgrading programs should be given to every eye care personnel to educate and train him with recent advancement and technology in their area of work. The eye care personnel training should also be initiated in some other institutions maintaining the international standards THE SIGHT, Vol. 5, Issue 5, September 2009 Page 40
Ocular Prosthesis - Raizada and as per need of the nation so as to meet Vision 2020 goals. Research is the fundamental element to measure the problem and success of the recent programs/interventions and implications of these are highly potential to change the quality of services. The current optometry and ophthalmology training should be strengthened with more involvement in community and extensive research opportunities. The career ladder has to be built up for OAs restructuring the course and giving them the academic value. It is very noteworthy that in any national blindness program or vision 2020 body or Apex body, the representation or participation of every professional body is essential so that fight against avoidable blindness can be easily conquered. The team work and importance given to every profession are keys to success. PEC should be given prime focus in every program and desire/commitment to work in the community should be developed among all of us. The motto of serving the unreached and the deprived only brings the milestone in the delivery of eye care services. References:
1. 2. 3. Definition of primary eye care, in Policy statement. 2005, American Academy of Ophthalmology Accessed date: 24 November 2008. Riad S.F., Dart J.K., and Cooling R.J., Primary care and ophthalmology in the United Kingdom. Br J Ophthalmol, 2003. 87(4): p. 493-9. Khan, M.A., Soni, M. and Khan M.D., Development of primary eye care as an integrated part of comprehensive health care. Community Eye Health, 1998. 11(26): p. 24-6. 4. Strategies for the prevention of blindness in national programmes: a primary health care approach- 2nd edition 1997, World Health Organization, Geneva. 5. Sapkota YD, Role of mid level ophthalmic personnel in Nepal experiences to share! Community Eye Health, Indian Supplement March 2009 22(69): s 119-121 6. Johnson GH, Foster A. Training in Community Ophthalmology. International Ophthalmology, 1990.14, 221-226 7. Upadhyay MP, Gurung BJ, Pillai KK, Nepal BP. Xerophthalmia among Nepalese children. American Journal of Epidemiology 1985. 121 (1); 71-77 8. Jha H, Chaudary JSP, Bhatta R, Miao Y, Holm SO, Gaynor B, Zegans M, Bird M, Yi E, Holbrook K, Whitcher JP, Lietman T. Disappearance of trachoma from Western Nepal. Clinical Infectious Diseases 2002;35:765768 9. Nepal Netra Jyoti Sangh Annual Report 2007. 10. Band-Aid Box Khari-Khola health camp- Eye team Report 2009, New Zealand Optics. August 2009 issue. 11. Naidoo K, Ravilla D. Delivering refractive error services: primary eye care centres and outreach Community Eye health Journal Sep 2007 20(63); 41-42
Prakash Paudel
School of Optometry and Vision Sciences University of New South Wales Sydney, Australia Email: paudel_prk@hotmail.com
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Ocular Prosthesis - Raizada
THE SIGHT
INVITED ARTICLE
Ocular Prosthesis: A Necessity of Ocular Disfigurement

Kuldeep Raizada, BOptom, MOptom, PhD
Introduction Ocularistry, the science of making ocular prosthesis, has undergone phenomenal growth in recent times. The ugly looks with disfigured eyes have higher impacts on individuals social and professional life. The customs made prosthetic devices alleviate such problem and are popular in the western world. Ocularistry is also evolving fast as a profession in South East Asia region and Nepal, currently with very limited practice and has high potential to flourish its market in the days ahead. This article aims to explore about the ocular prosthesis, its indications, manufacturing processes and also to create awareness of the cosmetic benefits of custom designed ocular prosthesis. History It is believed that the first artificial eyes were made by Egyptians. The Babylonian and Sumerian civilizations had probably used arteyes in mummies and statues, made from precious stone, silver or gold1-3. Ambrose Pare from Paris published a book in 1561 which describes two types of ocular prosthesis - one fitted underneath the eyelids called hyplepharon and the other fitted externally called eclepharon4. In the beginning of the nineteenth century, France became the centre of artificial eye making. Boissoneau in 1849 was credited with coining the term ocularist 5. He produced stock glass eyes, which were popular in Europe and America. 6, In 1853, Ludwig Muller Uri used a new material and method for making human glass eyes. His doll eyes were breathtakingly life-like7. He developed a unique method of colouring the iris. His nephew, Friedrich A Muller is credited with developing the double wall glass prosthesis7. Most of the commonly known ocular prostheses had been developed by the end of the last century. Peter Gouglemann, a student of Boissoneau had set up a studio of ocular prosthesis in THE SIGHT, Vol. 5, Issue 5, September 2009 1851, in New York5. During the Second World War, shortage of glass material led to the usage of a dental acrylic, methyl meth-acrylate (MMA). The first international organization in ocularistry was the American Society of Ocularists which came into being on October 13, 1958. Rapid advances have been made over the last 5 decades in the technique and materials used in making ocular prosthesis. Indications for Prosthetic Devices Prosthesis means an artificial device used to replace a missing body part 4. The various indications requiring prosthetic devices are divided into two broad categories namely congenital and acquired deformities. Anophthalmia and microphthalmia are congenital deformities, while acquired deformities include phthisis bulbi, atrophic bulbi, staphyloma, post evisceration, post enucleation, post chemical injuries. Types of Prosthesis The prosthesis used to improve the cosmesis in the orbital region can be broadly classified as ocular and orbital prosthesis. Ocular prosthesis can be further classified into stock and custom prosthesis with the latter referring to tailor made prostheses.
Ocular Partial Prosthetic contact lens Scleral shell Full thickness prosthesis Orbital Complete Spectacle prosthesis Adhesive prosthesis Magnetic prosthesis mounted retained retained
Prosthetic Contact Lens Prosthesis contact lenses are fitted over the scarred corneas with partial/total discoloration of cornea. A wide Page 42
Ocular Prosthesis - Raizada variety of soft and semi-soft contact lenses are available for cosmetic application. Scleral Shell versus Full Thickness Ocular Prosthesis Scleral shell is prosthesis with a thickness measuring less than 1.5 mm while a full thickness ocular prosthesis measures more than 1.5 mm in thickness. However according to the world dictionary of ophthalmic prosthesis by Kelly et all a scleral shell is defined as any ocular prosthetic device fitted over a residual globe like phthisis bulbi, atrophic bulbi or microphthalmos8-10. A full thickness ocular prosthesis is fitted in an orbit with no residual globe. Orbital Prosthesis Orbital prosthesis is indicated in conditions where there is additional loss of periocular tissues like eyelids, eyelashes and eyebrows. While fabricating an orbital prosthesis utmost care is taken to not only replace lost periocular tissue but match them in terms of colour and texture to the fellow orbit. However in this paper we are focused entirely on all aspects of ocular prosthesis, we will not be discussing much on orbital prosthesis. Material Used in Prosthetic Devices The materials used in prosthetic devices are glass, silicon and poly methyl methacrylate (PMMA). Glass was once the preferred prosthetic material, but owing to difficulty in moulding and its fragile nature, it is seldom used today. However glass eyes are still fabricated in some parts of Europe. Modern ocular prostheses are fabricated using PMMA11. Ease of moulding into any desired shape and its intrinsically inert nature make it the material of choice in fabricating ocular prosthesis. Silicon is the material of choice in fabricating the orbital prosthesis with the periocular skin and pattern. It is nonreactive, moulds easily and above all the desired skin texture can be created over the surface. Method of Fabrication of Custom Made Ocular Prosthesis The procedure of fabrication involves the following steps: 1. Preparation of the Patient The patient should be reassured that taking an impression is less uncomfortable than the insertion of a trial prosthesis shell. The patient must keep the THE SIGHT, Vol. 5, Issue 5, September 2009 e on a 2. Taking an impression With the patient sitting on a chair and looking at ceiling, makes the impression much easier. Topical anaesthetic is instilled and the moulding material is prepared with a spatula in a rubber bowl. The mixture is placed in the syringe with the help of a flat spatula. While placing the moulding shell (also called as impression tray) on the eye, the patient is instructed to look in down gaze, the upper lid is retracted and the shell is first inserted underneath the upper eyelid followed by the lower eyelid. Then, the syringe is attached to the shell and moulding material injected gently. The moulding mixture gels in about two minutes. The gelled mixture has the consistency of a hard-boiled egg. 3. Removing the impression The upper and lower eyelids are gently retracted and the shell handle is drawn towards the eyebrows along with a side-to-side rocking motion, which allows release. After the removal the shell is immersed in water. 4. Moulding the impression into the wax model Half a cup of distilled water is taken and mixed thoroughly with the one spoonful of alginate. This paste is then poured in a plastic cup and the rear surface of impression. The alginate hardens in about 2-3 minutes. The alginate mould is cut along the lines drawn on the impression tray. The carving wax is heated in a steel bowl till it becomes liquid. The molten wax is poured into the alginate mould and allowed to harden. An exact replica of the socket impression is now created. 5. Centration of the iris Centration of the iris and marking the corneal plane is essential to achieve symmetry of the two eyes. Various methods used to achieve symmetry are: 1. Using the inter-pupillary distance (IPD): Once the wax model has been made, wax solvent is used to smoothen the surface. This wax model is inserted in the patients socket. After making it symmetrical with respect to its position and plane, the interpupillary distance is marked with a non-toxic marker. Page 43
Ocular Prosthesis - Raizada 2. Using Hirschbergs test: In absence of gross asymmetry of the orbit and plane, the base for the ocular prosthesis can be made in white acrylic and inserted into the socket. The light reflex is kept at the centre of the model. 3. Inscribing a circle: On the white acrylic base, based on the ocularists judgment a circle is inscribed in the centre corresponding to the fellow eye. 4. Using iris corneal buttons: This is the most difficult of the various methods described above. However this gives the best cosmetic result. The iris button is inserted in the wax model using the carving wax and hot metal spatula and symmetrise by trial and error. correction of ptosis, ectropion and cicatricial bands. It will then be further evaluated for Comfort, Stabilization, Vertical and horizontal position, Motility, Iris and sclera colour, Iris position, Iris size, Pupil size, Anterior curve, Posterior curve. Finally instructions on socket hygiene and prosthetic care are given to the patient along with the technique of removal and insertion. Ideal Prosthesis Prosthesis with a total thickness about 7 mm anteroposteriorly ideally should have 1 mm thickness for the iris disc, 3 mm for anterior chamber and another 3 mm for the peg. It should be light exerting minimal to no pressure upon orbital tissues in the socket. It must achieve acceptable conversational movement in all gazes12. The material must be inert in nature. It should effectively correct the volume deficit and match the appearance of the fellow eye as well. If the socket does not meet these criteria, most often the cosmesis is compromised.
Once the wax model is finished, a 2-piece mould in the dental stone is prepared. The white base of the PMMA is poured into the moulds and cured at 110o C temperature and at 4-bar pressure. Once cured, it is taken out from the mould and the edges are trimmed, polished and inserted into the patients socket. While doing so we reconfirm the size, plane and angle of the iris in the Ideal Socket white base. If satisfactory symmetry and cosmesis is visualized, the corneal button is exposed and the process Kaltreider12 defines an ideal socket as a socket with of tinting is begun. Cotton rayon threads are used to give adequately deep fornices, the volume loss not the appearance of blood vessels. Dry, stable, natural, fine exceeding 4.2 ml. It should have a well-centred grinded colour pigments are used to give the exact shade orbital implant with quiet conjunctiva and no to the sclera corresponding to the patients fellow eye. granulomas. There should be no blepharoptosis, Once it is ensured that the exact colour matching has eyelid malpositioning or laxity, sulcus deformity, been achieved, the base of the prosthesis is kept in the socket contracture, lagophthalmos. Very often socket oven at 85o C for 30 minutes. This cures the colours to does develop various kinds of deformities and thus saturation levels and prevents any future fading. Once fitting of a prosthesis is really a challenge. Lee Allen the artwork is completed, the shell is put back into had described in the literature of correcting the mould and a layer of clear plastic is polymerized on the various deformities using the modified impression front surface, completing the fabrication process. After technique. trimming and polishing, the final prosthesis may need minor adjustments such as adding or removal of PMMA Prerequisites for a Good Prosthetic Fitting in different places for opening or closing the lids, The prerequisites for good fitting of a prosthesis are adequate orbital fat, well-centered and covered orbital deep fornices in all quadrants, normal tear secretion, implant and absence of socket inflammation. effective volume replacement with orbital implants, As in most of the cases, impression of the prosthesis need to be modified, due to socket uniqueness, as Lee Allen already had described the various method and thats why most of the time even in the absence of ideal socket a good cosmetic appearance can be achieved with the modified impression technique (MIM). In the absence of inadequate space in the cavity, socket reconstruction surgery can be performed and later custom prosthesis can be provided.
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Quality of life in Low Vision Patients Gyawali
Important Consideration Movement of prosthesis depends on the size, type of orbital implant and the fitting of a custom ocular prosthesis. To cite a few examples, an inferiorly migrated implant will exhibit sub optimal movement in all directions. Similarly small implant size makes it deep seated and therefore does not allow optimal transfer of movement to the overlying prosthesis. Compared to a non-integrated implant an integrated one shows much better movement especially when coupled (either with peg or magnets) to the ocular prosthesis. Therefore prevention of socket contracture by minimal tissue handling by the surgeon followed by custom fitted ocular/orbital prosthesis gives excellent cosmetic results. Advances in Ocular Prosthesis Traditionally ocular prosthesis has been associated with dryness, allergy, limited ocular movements and laxity of lower eyelids. The lower lid laxity by solid prosthetic devices led to the creation of hollow prosthetic devices. This reduces 26% overall weight of the prosthesis. Self Lubricating Ocular Prosthesis called SLP13 provides the needed lubrication to the artificial eye surface for the relief of dryness and related problems. This kind of special prosthesis is of great help for the radiated anophthalmic sockets and dry anophthalmic sockets. Achieving near normal motility of the prosthesis has been the subject of extensive research. Improvement in prosthesis motility has been achieved by improvement in surgical technique like myoconjunctival technique and use of integrated implants. Pegging of the orbital implants allows direct transfer (90-95%) of motility to the prosthesis. The appealing design and techniques are emerging as further researches are being conducted to advance the current techniques.
Reference
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. Gray PHK: Radiography of ancient Egyptian mummies ,Medical radiography and photography 1976: 43:34-44 Gordon B : the ancient origins of artificial eyes, In : Annuals of medical history, ed 3 ser 2, New York, 1940 Martin O, Clodious L: the history of artificial eyes, Ann plastic surg 1979;3: 168-170 Pare A: Cimbrosie, paris, oruveres, 1561: 648-650 Boissonneau M: Yeux, artificial mobiles, Paris, Ritterich, 1849:10 Muller F G: Charter member A.S.O., honorable member A.S.O., boulder, CO, written communication 1988 Schrieber EC: Charter member A.S.O., honorable member A.S.O., boulder, CO, written communication 1988 Merbs SL. Management of a blind painful eye. Ophthalmol Clin North Am. 2006 Jun; 19(2):287-92. Smith AR, O'Hagan SB, Gole GA. Epidemiology of open- and closed-globe trauma presenting to Cairns Base Hospital, Queensland. Clin Experiment Ophthalmol. 2006 Apr; 34(3):252-9. Song A, Carter KD. Bilateral traumatic globe subluxation.Ophthal Plast Reconstr Surg. 2006 Mar-Apr; 22(2):136-7. Gouglemen Paul: fitting of prosthesis for patients with creptophthalmos and extreme microphthalmos , Arch ophthlal., 18:774-776,1937 Kaltreider, Sara A. M.D. The Ideal Ocular Prosthesis: Analysis of Prosthetic Volume. Ophthalmic Plastic & Reconstructive Surgery. 16(5):388-392, September 2000. Kevin V Kelly: the SLP, Self- Lubricating Prosthesis, 25th edition 1994 American society of ocularists 26-30, 1994
Kuldeep Raizada, PhD

Ocular Prosthesis Services, LV Prasad Eye Institute Hyderabad, India
Page 45

Email:ocularist@gmail.com, www.lvpei.org
Figure 1: Patient with microphthalmic socket (left eye)
Figure 2: The same patient with custom ocular prosthesis in Left eye
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THE SIGHT
REVIEW ARTICLE
Quality of Life in Low Vision Patients

Rajendra Gyawali
Low vision and vision impairment Visual function is important for an optimal orientation in functional and social life and has an effect on physical and emotional well being. The International Classification of Functioning, Disability and Health (ICF) provides a useful context for understanding health outcomes. According to ICF, disorders of the eye and other organs of the visual system result in impairments in seeing functions, which are sub-classified as visual acuity function, visual field functions and quality of visual functions1. Low vision may result from many different ocular and neurological disorders. Disorders of the visual system include any diseases, injuries or abnormal development affecting the eyes or their neural connections. The ensuing visual impairments may interfere with an individuals ability to perform work and their ability to participate in daily living and leisure activities2. This deficit vision performance is described as a visual impairment3. Vision loss is not dichotomous, but occurs as a continuum that ranges from modest low vision to total blindness. WHO estimates that there are 140 million people worldwide with low vision, 35 million of which require services because their vision loss is untreatable4. The prevalence of low vision in Nepal is increasing dramatically as the baby boomer population ages and becomes more vulnerable to sight-limiting conditions associated with aging.5 Low vision rehabilitation The primary role of vision rehabilitation is to help people maximize functional independence, maintain quality of life and adapt to the psychosocial aspects of their vision loss. Low vision rehabilitation allows people with visual impairments to use their limited residual vision as optimally as possible, with the use of assistive devices and technologies2,6. The intention is to restore lost function and to limit or minimize any related THE SIGHT, Vol. 5, Issue 5, September 2009 disabilities. Rehabilitation services are intended to achieve positive outcomes in one or more of the following domains: cognition, communication, functional independence, mobility, occupational performance, perception, physical function, psychological well being, quality of life, social skills and socialization. Vision rehabilitation can be very successful at reducing costs and prolonging an individuals independent activity and contribution to society despite the visual impairment2. Some of the issues that individuals face when attempting to access services are: lack of awareness of services, transportation, ineffective communication between patients and eye care practitioners, money, and stigma of low vision services5. Many individuals with impaired vision fail to obtain vision rehabilitation services because they are unaware of the potential benefits or because the available service is difficult to access. Quality of life In newer economic era the definition of quality of life (QOL) includes the fulfillment of basic needs, pursuit of happiness and a general sense of well being. The current approach, reported by Aaronson19, is to view QOL as multidimensional by including: 1. Physical: disease symptoms and their treatment 2. Functional: self care, mobility, activity level and daily leaving activities 3. Social: social contacts and interpersonal relationships 4. Psychological: cognitive function, emotional status, well being, life satisfaction and happiness. QOL has been defined as the degree to which an individual enjoys the important possibilities of his life.7,8 It is dynamic and changes over time and over a persons Page 47
Quality of life in Low Vision Patients Gyawali life. It arises from a persons interaction with his environment and is experienced differently from person to person, but has the same components for everyone. 9 In management and rehabilitations of disorders and disabilities, health care providers give priority to improve the physical and functional aspect of QOL, whereas the patients emphasize on social, emotional and psychological aspects. Consequently it has been established that obtaining the patients point of view is of prime importance when evaluating health (so the vision) care outcomes. Also, the recent findings suggest that patient-perceived vision related quality of life (VRQOL) should complement, not replace, the traditional measure of functional vision, such as visual acuity, contrast sensitivity, as a part of standard patient care.16 Low vision and Quality of life As the population of low vision patients continues to grow, attention must be focused on evaluating the effect of impaired vision on patient-perceived QOL and the effectiveness of the low vision services especially because it is reported that about 90% of individuals affected by low vision maintain sufficient vision to benefit from training in the use of optical and nonoptical devices and adaptive skills. Successful low vision rehabilitation is often subjective and its success may be determined by whether the individual feels his/her assistive device has helped or not. Rehabilitation should be ongoing rather than short term since generally with the progression of a condition or disease, an individuals general health and mental status may tend to also deteriorate8. Assessment of QOL prior to and after low vision rehabilitation is very important to know whether the patient is benefitted from the rehabilitation or not. Measurement of Health/ vision related Quality Of Life The literature on quality-of-life measurement includes both general health measures and disease-specific measures. General health status measures such as the Sickness Impact Profile (SIP)10 and the Medical Outcomes SF-3611 address different populations and THE SIGHT, Vol. 5, Issue 5, September 2009 cover many health issues. These are generic in determining the effects of various diseases on different aspects of quality of life. Disease-specific instruments measure quality of life relative to specific diseases and their treatment. These scales have been reported to be useful measures in relation to each condition alone, but are incapable of comparing the effects of different diseases.12 Both generic and disease-specific measures are often included in the same investigation. Patrick and Deyo12 noted that a disease-specific measure should be responsive to changes in vision and that a more generic measure should be used for comparison with the other conditions and populations. As an example, the National Eye Institute Visual Function Questionnaire (NEI-VFQ)25, a vision questionnaire with scale battery, can be combined with SF-36, a general health status questionnaire. The need to develop instruments to measure both general and specific visual disorders is recognized by the scientific community. Although scores of general healthrelated quality-of-life questionnaires and their subscales independently predict visual acuity,13 they are not sensitive to severity of impairment in ocular diseases such as age-related macular degeneration (AMD)14 and glaucoma15 or changes in functional status after lowvision services.16 Vision-specific measures including the VF-1417 and NEI-VFQ15,16 are more sensitive to decreased functional status secondary to vision loss than the general health-related quality-of-life measures such as the SF-36 and SIP. Additional instruments are needed. They should be sensitive to changes both short term and long term after low-vision rehabilitation for patients with a continuum of vision loss including both the legally blind and visually impaired. Questionnaires with short administration times and the potential for administration by volunteers or assisted by family members before a low-vision clinic appointment are important in managedcare environments. Instruments must be clear and have concise language because previous studies18 indicate that elderly patients are confused by frequent changes in format and ambiguity in questions. Instruments should be sensitive to skills taught in rehabilitation and contain Page 48
Quality of life in Low Vision Patients Gyawali enough items to assess individual patient needs and progress, techniques, devices, programs, and their relative costs and benefits. Attention must be paid to measurement properties, validity and reliability. References
1. World Health Organization. International classification of functioning, disability and health: ICF. Geneva, World Health Organization. 2001. Jutai, J. Hooper, P. Strong, G. Cooper, L. Hutnik, C. Sheidow, T. Tingey,. Vision rehabilitation evidence based review: Chapter 1: Terminology, demography, and epidemiology of low vision. CNIB Baker Foundation for Vision Research. 2005; 1:1-60. Massof RW. A systems model for low vision rehabilitation. II. Measurement of vision disabilities. Optom Vis Sci. 1998; 75:349-373. Pollard TL, Simpson JA, Lamoureux EL, Keeffe JE. Barriers to accessing low vision services. Ophthalmic Physiol Opt. 2003; 23:321-327. Paudel P., Khadka J., Sharma A.K: Profile of a low vision population. International Congress Series 2005; 1282:252-256 Bischoff P. Long term results of low vision rehabilitation in age related macular degeneration. Doc Ophthalmol. 1995; 89:305-311. Jutai J. Quality of life impact of assistive technology. Rehabilitation & Community Care Management. 1998; 14: 207. Jutai J. Measuring the psychosocial impact of assistive technology. 16th Annual Conference on Technology and Persons with Disabilities. 2001 Day H, Jutai J, Campbell KA. Development of a scale to measure the psychosocial impact of assistive devices: Lessons learned and the road ahead. Disabil Rehabil. 2002; 24:31-37. 10. Bergner M, Bobbitt RA, Carter WB, Gilson BS. The Sickness Impact Profile: development and final revision of a health status measure. Med Care 1981; 19:787-805. 11. Ware JE, Snow KK, Kosinski M, Gandek B, New England Medical Center. Health Institute SF-36 Health Survey: Manual and Interpretation Guide. Boston: The Health Institute New England Medical Center, 1993. 12. Patrick DL, Deyo RA. Generic and disease-specific measures in assessing health status and quality of life. Med Care 1989; 27:S217-32. 13. Scott IU, Schein OD, West S, Bandeen-Roche K, Enger C, Folstein MF. Functional status and quality of life measurement among ophthalmic patients. Arch Ophthalmol 1994; 112:329-35. 14. Mangione CM, Gutierrez PR, Lowe G, Orav EJ, Seddon JM. Influence of age-related maculopathy on visual functioning and health-related quality of life. Am J Ophthalmol 1999; 128:45-53. 15. Parrish RK, Gedde SJ, Scott IU, Feuer WJ, Schiffman JC, Mangione CM, Montenegro-Piniella A. Visual function and quality of life among patients with glaucoma. Arch Ophthalmol 1997; 115:1447-55. 16. Scott IU, Smiddy WE, Schiffman J, Feuer WJ, Pappas CJ. Quality of life of low-vision patients and the impact of lowvision services. Am J Ophthalmol 1999; 128:54-62. 17. Steinberg EP, Tielsch JM, Schein OD, Javitt JC, Sharkey P, Cassard SD, Legro MW, Diener-West M, Bass EB, Damiano AM, Steinwachs DM, Sommer A. The VF-14: an index of functional impairment in patients with cataract. Arch Ophthalmol 1994; 112:630-8. 18. Stelmack J, Szlyk J, Joslin C, Swetland B, Myers L. Pilot study: use of the NEI VFQ-25 to measure outcomes of low vision rehabilitation services in the Department of Veterans Affairs. In: Stuen C, Arditi A, Horowitz A, et al., eds. Vision Rehabilitation: Assessment, Intervention and Outcomes. Lisse, The Netherlands: Swets & Zeitlinger, 2000: 774-6. 19. Aaronson NK. Quality of life: what is it? How should it be measured? Oncology (Huntingt) 1988; 2:69-76.
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Rajendra Gyawali
Bachelor of Optomety VIII Batch, IOM Email: thegyraj@gmail.com
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School Eye Screening Kaiti and Manandhar
THE SIGHT
ORIGINAL ARTICLE
School Eye Screening in Kathmandu Valley

Raju Kaiti, Sarita Manandhar
Introduction About 1.4 million of children are blind world wide1. This comprises of only 3% of total blind population. But, the blind children have a lifetime of blindness ahead of them. In country like ours, where the blind people dont get proper facility and opportunities, blindness is a burden to the society and nation. The main causes of blindness in children are refractive error, congenital cataract, corneal scarring due to vitamin A deficiency, congenital glaucoma, retinopathy of prematurity etc. However, many of these causes of blindness are preventable or curable if intervened in time. Hence, different programs and strategies have been proposed for the prevention of childhood blindness. Control of pediatric blindness is a major priority of VISION 2020: The Right to Sight. Nepal Optometry Students Society (NOSS) has been conducting School Vision Screening programs since few years as a small contribution in the prevention of childhood blindness. Methods and Materials The screening is based on the Indiana School Vision Screening Guideline 2 and modified clinical technique. Students of different schools of Kathmandu and Bhaktapur were screened in the school premises. All the students attending the school on the day of screening were included in the study. The schools were informed in appropriate time and arrangements were made. The screening team included a group of optometry students supervised by optometrists and ophthalmologists. The examination tools taken with the screening team were Snellens chart, torch lights, ophthalmoscope, retinoscope and Trial set. The students underwent following examinations: Visual acuity: unaided, with pin hole, and with glasses at a distance of 6 meters Binocular vision assessment: Cover test, Hirschbergs test, Extra ocular motility test, and Convergence Anterior segment evaluation with torch light Fundus evaluation with a direct ophthalmoscope Dry retinoscopy with subjective refraction The students requiring detailed dilated fundus evaluation, cycloplegic refraction and those with any other pathology or disorders were referred to eye hospital. Results A total of 2963 students from 8 schools of Kathmandu Valley were screened in the year 2065/66. There were 1566 male (52.85%) and 1397 female (47.15%) of age between 3 years to 16 years. Among them, 570 students (19.24%) had some ocular abnormality, comprising of 320 (56.14%) male and 250 (43.86%) female. Out of them, 142 (24.91%) required referral. Refractive error was the most common abnormality, found in 347 students (61%) among all abnormalities (fig.1). Other abnormalities seen were Conjunctivitis and conjunctival disorders in 64 (11.22%), Binocular vision problems in 49 (8.67%), suspected Glaucoma in 38 (6.63%), Amblyopia in 26 (4.59%) and disorders of Lid and adnexa in 16 (2.55%). Besides these other disorders like Chorioretinal scars, Nightblindness, Suspected disc edema, Nystagmus etc. were found in 30 students (5.34%).
THE SIGHT, Vol.5, Issue 5, September 2009
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Optometry as a Practice: Marasini The most common type of refractive error observed was Simple myopia accounting for 74.63%, followed by astigmatism, 19.60% and hyperopia, 5.77%. In this study, it was observed that there were more male than female. The ocular and visual disorders also prevailed more in male than in female. There were more male with refractive error and BSV related problems than female.
Others Fig. 1 Ocular Morbidity 5% Lid Amblyopia disorders 4% 3% Glaucoma suspects 7% BSV abnormaliti es 9% Conjunctiva l disorders Refractive 11% errors 61%
Fig. 2: Gender and morbidity

250 200 150 100 50 0 199 148 2440 Males Females 3019 2018 17 9 97 1713
Discussion The results showed that 19.24% of the total school students had ocular and visual morbidity. In a similar study done in 2003, Adhikari S. et al3 found 11% of ocular morbidity in school students whereas in the similar school screening4 conducted in year 2064/65 by NOSS, the ocular and visual morbidity was present in 14.93%. Refractive error was found to be the commonest abnormality prevalent in 11.72% of the total students. It is little higher than the screening conducted in 2064/65 (7.5%) and Adhikari S (8.1%)3. The commonest refractive error found in this study was myopia followed by hyperopia. These findings are similar to that of 2064/654 and Adhikari S.3 Binocular vision abnormalities, including intermittent exotropia and strabismus were found in 1.65% of total. In 2064/653 it was reported in 2.02% whereas Adhikari S3 reported in 1.6%. Glaucoma suspect was found in 1.28% of students which is similar to study of 2064/65(1.3%) 4. Vision not improving better than 6/18 with refractive correction (with consistent refractive error and/or strabismus) was diagnosed as amblyopia. In our study, amblyopia was observed in 0.87% of the total students. Lid and adnexa related problems were prevalent in 0.54% and conjunctival disorders were present in 2.16%. These results are similar to the study of NOSS in 2064/65.4 Conclusion The vision screening program has proved to be very helpful in early detection, diagnosis, referral and management of prevalent ocular morbidities in school children. The refractive error was found to be the commonest morbidity in school children. Many children have also developed amblyopia. Hence, timely intervention and management by appropriate glasses can prevent the children from being visually handicapped. Vision is equally important for everybody whether one is a child or an adult. But a child, however, has to bear the burden of visual impairment for years to come. Moreover, the children are the future stars who will lead the society to development. Nepal Optometry Students Society believes that this small step can prove to be boon to somebody. THE SIGHT, Vol. 5, Issue 5, September 2009 Page 51
Optometry as a Practice: Marasini
References
1. 2. 3. 4. Wilson, JM.; YG. Screening for Disease. Geneva; world health organization; 1986 Indiana School vision Screening Guidelines, Third edition 2000 Adhikari S, Nepal BP, Koirala S, Sharma AK. Ocular Morbidity in school children in Kathmandu. Br J ophthalmol 2003;87:531-534 Gyawali R. Little optometrists: On its Way. The Sight. 2008;31-34
Raju Kaiti, Sarita Manandhar Bachelor of Optometry Maharajgunj Campus, Institute Of Medicine Email: ujaratis@yahoo.com Sorrie_ta@yahoo.com
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Optometry as a Practice: Marasini
THE SIGHT
Clinical Pearls Know Your Patients

Sanjay Marasini, BOptom.
With the knowledge you have acquired in your degree, you are winning the spirits of life. A graduation is not just a certificate; its the proof that you are capable of living independently even though you are in a solitaire corner of the world. Knowledge, practice and the technical aspects that you correlate in your medical practice are the things those breed your desire to the level you want. Only the theoretical knowledge gained by reading books is not enough to cure patients. Examining patients and curing diseases are not the only aims of professional practice. To be a successful practitioner, you have to own patients; you have to win their psychology. An optometric practice in our scenario is a unique one because we have patients with not only visual complaints but also general ocular complaints and sometimes even systemic ones. It is supportive if we initially get chance to work under the supervision of seniors. In todays competitive world, where there are multiple intra and inter-professional competition, there will be someone always watching at your wrong steps. As a primary vision care professional, we meet most patients with complaints of headache. Most patients think that their eyes are the culprits behind their headaches. After thorough examination of the eye and visual system, most of them get a diagnosis of ocular NAD (no abnormality detected). Now it causes a headache thinking how to counsel this patient. Time and again it has been confirmed that even the plane glasses could wipe away the minor degree of headaches. Some patients dont want to wear glasses even when they have to. Proper counseling, follow up, and referral are essential in such cases.
While dealing with patients, psychological aspects should be kept in mind. If the patient is not ready for glasses even after best counseling, it will be better not to force. Alternatively we may teach about the importance of environmental modifications like appropriate illumination, rest in between prolong near work, proper adjustment of computer screen etc. To deal with patients in private settings is more difficult than in hospitals because patients easily adopt the clinician in hospitals. In private setup, few points should be considered while dealing with patients. Problems should be handled privately in soft voice. The problem should be listened in a kind and caring manner. The best way to start is to give the complainer an opportunity to vent. Once you feel that you've done a good job of listening, ask yourself "Is there anything else I need to know?" Tell patients the details of the diseases or ocular problems they have in a simple language. It is better not to try to treat every condition, which you are not the master of. Patients can be made happy sometimes only by appropriate referral. If confused, its always better to discuss the case among the colleagues about the pathological consequences and the ultimate management techniques; it satisfies both the clinician and the patients. Its hard to please all, but every time someone walks out the door unhappy, you've lost a lot in terms of future business and referrals.
Sanjay Marasini
Optometrist Dhulilkhel Hospital, Kathmandu University Kavre, Nepal Email: thesanzay@gmail.com Page 53
Family of Visually Impaired Child - Puri
THE SIGHT
REVIEW ARTICLE
Family of a Visually Impaired Child

Sudan Puri
When a couple expects a baby, they have dreams of their life after the birth of the baby. Although these expectations are individual, some are universal. They expect that their child will be able to live out their dreams and hopes without any unreasonable harm. When a family first learns that their child probably does not see well, they are devastated. The diagnosis of visual impairment in a child has an enormous emotional impact. Confusion, shock, helplessness, fear, depression and profound sadness overwhelm everyone involved. The family no longer feels the same safety that they had before the diagnosis. After the diagnosis, the family feels every cough is pneumonia, every headache a brain tumor, every activities are laden with dangers. The concept of visual impairment has gradually changed from acuity, field size and legal blindness to a more functional definition, which includes ocular and brain condition with acuity loss, eye movement disorders and visual inattentiveness which prevent the effective use of vision. Many children with severe visual impairment exhibit one or more types of self-stimulating behaviors, which are also called blind mannerism. It results from disordered physiological mechanisms therefore when they occur, they need to be carefully analyzed and then appropriately managed. The stereotyped behaviors related to blind mannerism include eye rubbing, pressing, poking, gazing compulsively at light, staring at hands, flicking fingers in front of the eyes against a light source, pulling on eyelids, tapping or hitting their globes, and repeatedly blinking or rolling the eyes. There are a number of self-stimulating behaviors; characterized by repetitive motor activities, such as rocking, headrolling, body-swaying, twitching, tapping and hand flapping. These stereotyped behaviors diminish or even entirely disappear when there is exposure to appropriate physical activity. Introducing the parents to the fact is a hard task. The manner in which the parents are told, can positively or adversely affect them and their children for years to come. Thus, it is crucial for all physicians to examine their own feelings and then convey the diagnosis truthfully, in lay terms, with compassion, patience and optimism but without giving unrealistic hopes for visual recovery and to allow time for questions. They should not be hesitant to show their feelings to avoid the complaint of the doctor did not care. Most mothers have guilt feelings that they did something wrong during pregnancy responsible for the impairment. Even when they dont mention their guilt, it needs to be strongly stated that it is not their fault. Parents should not be expected to accept what is, to them unacceptable . Their not being willing to accept the situation by expressing anger does not make them bad or difficult parents- but just normal ones. The rehabilitation of visually impaired children is based on the fact that their physical, emotional and intellectual growth responds to skilled, early interventions. The professionals assigned as visual consultants (Optometrists) must first develop a trusting relationship with the parents and subsequently keep them advised on development issues. Without understanding the childs abilities and weaknesses, it is difficult to advise the family and may even be harmful, if incorrect information is given. Children who are raised in a proper stimulating environment provided by loving, informed parents supported by vision professionals develop faster than when they are under-stimulated. Blind infants may not turn their heads or show the expected motor responses to auditory clues, and as a result, they are occasionally misdiagnosed as being deaf. For visually impaired children to learn from their hearing, structuring of the environment is required by minimizing background noises especially from radio or TV and they need Page 54
Family of Visually Impaired Child - Puri encouragement to listen to meaningful sounds. The vision specialist must interpret the childs signals to the parents and encourage them to keep their babies nearby and talk to them often in order to develop a strong relationship. Because they need more structure and predictability in their environments, they are often more resistant to change, while their behavior may appear rigid. The technological revolution has had a markedly beneficial effect on the visually impaired. When assistive technology is offered, the visual and intellectual abilities are evaluated, costs and issues considered, devices are selected, adjusted and maintained, the school and home environments are often modified, the students, parents and educators are instructed how to use them. Thus the family of a diagnosed visually impaired child needs a great deal of support, understanding and non judgmental help along with proper interventions from vision specialists.
Sudan Puri
XI Batch, Bachelor of Optometry Maharajgunj Campus, Institute Of Medicine Kathmandu Email: sudanpuri@hotmail.com
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Stroke and eye - Upadhyaya
THE SIGHT
ORIGINAL ARTICLE
Profile of Contact Lens Service in Mechi Eye Care Centre

Digen Sujakhu, BOptom, Gyan Bahadur Basnet, BOptom, Purushottam Joshi, M.D
Abstract Background: Mechi Eye Care Centre (MECC) has large catchment area. To meet the need and demand of the wide spectrum benefits of contact lenses (CL), MECC started its CL service in Jan 2001. Currently, different types of CLs (soft sphere, soft toric, rigid gas permeable, and bandage, prosthetic/cosmetic) are in practice in MECC. Methods: Total of 301 patients (467 eyes) was enrolled from CL Department, MECC. Slit-lamp examination, retinoscopy, schirmer II, Invasive tear break up time (IBUT) and fitting assessment were done. Results: Males (60%) were dominant and mostly people from age group 11-30 years (82%) sought CL service. UCVA was <6/60 in about 66% of total eyes while BCVA was > 6/18-6/6 in 79%. CLs were dispensed to about 82% of the total trial of which soft sphere constitutes 60% . Power ranging from 0.00-5.00D were dispensed more (41%) followed by 5.00-10.00D (27%) for minus lenses. Conclusions: People from age group 11-30 years (82%) wanting overseas jobs sought for CLs service. BCL and prosthetic CLs were frequently practiced in cases of corneal trauma due to agricultural work. CLs are effective for refractive, therapeutic and cosmetic purposes. Key words: soft sphere, soft toric, RGP, prosthetic, bandage CL
Introduction CLs are used for various purposes such as optical, therapeutic, cosmetic, diagnostic, the first being mostly used for. Different types of lenses (soft sphere, soft toric, RGP, cosmetic/prosthetic, X-chrome lenses, prosthetic shell, and scleral lenses) are in practice according to the condition of eyes. In present competitive and dynamic world, CLs are widely used, youth being the dominant. Lenses are very much easy in job places, sports, social activities and glamorous field. Similarly disfigured and special pathologic eyes benefit more from special CLs. So, demand of CLs is increasing day by day. MECC has a large catchment area including the neighbouring countries like India, Bangladesh, and Bhutan. To fulfill the wide spectrum benefit and needs of patients, CL service was started in MECC in Jan 2001.MECC at present dispense different types of lenses like soft sphere, soft toric, RGP, cosmetic/prosthetic. This study aims to study the profile of CL service in MECC regarding the profile of CL patients, type of CL prescribed and range of power prescribed. Methods and methodology It was a hospital based cross-sectional as well as retrospective study conducted at Contact Lens Department of Mechi Eye Care Centre for one year duration (March 2008-Feb 2009). Visual acuity (VA) measurement, slit lamp examination, refraction, keratometry, Schirmer II test, invasive tear break up time (IBUT) and contact lens trial were performed in all patients included in the study. Results Among 301 patients, 60% (181) were male. The most common age group was 21-30 years (43%) followed by 11-20 years (39%). Most of the trial was done for soft spherical contact lens (65%) followed by soft toric (13%), Bandage (8%), Prosthetic and cosmetic (8%) and RGP lens (6%). Majority of patients had refractive error from 0.00 D to 5.00 D as shown in the graph.
45% 40% 35% 30% THE SIGHT, Vol. 5, Issue 5, September 2009 25% 20% 15% 16% 28% 42%
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Fig.: Distribution of lens power trialed for minus and plus lenses. . Majority of the study population had UCVA < 6/60 but with CLs 79% of them gained VA >6/18-6/6. About two third of patinets (76%) had BCVA >6/12-6/6 with soft sphere lenses. Majority (61%) of the population had BCVA > 6/12-6/6 with spherical RGP lenses and 70% of patients wearing soft toric lens obtained BCVA >6/12-6/6.More than half of total dispensed CLs (59%) were soft spherical followed by bandage (14%), soft toric (12%), prosthetic (10%) and RGP (5%). Among all the patients for whom CL trial was done, 241(80%) were dispensed with CL. Discussions and conclusions Male population was more dominant for seeking CL service. Youth of 11-30 years age group (82%) and people seeking overseas jobs demanded CL service more than others. BCL and prosthetic CLs were also frequently dispensed. More chance of ocular injury during work in farm and subsequent corneal ulcers may demand BCL for quick healing. At the same time to avoid social stigma due to disfigured eyes prosthetic CLs were used more. RGP lenses were less dispensed compared to soft toric which may be due to easy and comfortable vision with the later. CL is effective for refractive, therapeutic and cosmetic purposes. Even in Jhapa, the most eastern part of Nepal, far away from the capital, demand for CL is high. Digen Sujakhu
Optometrist, Mechi Eye Care Centre Jhapa, Nepal Email: djn_sujakhu@yahoo.com
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THE SIGHT
REVIEW ARTICLE
Stroke and Eye

Suraj Upadhyaya Pokhrel Eye is a part of brain. Stroke is a vascular-origin pathology associated with brain injury of a focal area or as a whole, causing different motor and sensory anomalies, and lasting for more than 24 hrs. Impact of stroke may vary from recovery within a week to a devastating condition of death. After stroke, vast majority of people can survive due to advances in medicine. Millions of stroke and traumatic brain injury survivors suffer from visual problems. Each case is a different one and the difficulty each patient has depends on the severity and location of the injury. The visual problems can be visual field defects, reading disorders, ocular motility dysfunctions (exotropia, esotropia and hypertropia, accommodative problems, convergence problems, eye movement disorders, fixation, pursuits, diplopia, nystagmus), visual hallucination, unformed stars, lighting bolts, unstable ambient vision, visual perceptual disturbances, disturbances in body image, disturbances of spatial relationships, right - left discrimination problems, agnosia (difficulty in object recognition) and apraxia (difficulty in manipulation of objects). the other possible ocular problems are cranial nerve paresis/paralysis III, IV, VI, VII, lagophthalmos, dry eye and decreased blink rate. Patients with stroke may also face various visual perception problems like: o o o o Visual-Motor Integration- Eye-hand, eye-foot, and eye-body coordination; Visual-Auditory Integration - The ability to relate and associate what is seen and heard; Visual Memory - The ability to remember and recall information that is seen; Visual Closure - The ability "to fill in the gaps", or complete a visual picture based on seeing only some of the parts; Spatial Relationships; o o Figure-Ground Discrimination - The ability to discern form and object from background; Visual motor problems like inability to steadily and accurately gaze at an object of regard.
Many brain injury patients feel disoriented because of the above mentioned visual problems and this is a type of Post Traumatic Vision Syndrome. Unfortunately, many patients with visual problems after a stroke or head injury fail to receive adequate vision rehabilitation. Hence, complete eye examination of the stroke survivor is essential to improve their quality of life. A new field of eye Neuro-Optometry deals with the rehabilitation of such patients.
References: 1. Booklet 2. 3. 4. 5.
of Neuro Optometric Rehabilitation Association about stroke. Johansen A, White S, Warmish P, Screening for Visual impairment after stroke: Arch Gerontol Geriatric 2003; 36: 289-293. Macintosh C. Stroke re-visited: visual problem following stroke and their effect on rehabilitation. Br Orthoptic journal 2003; 60:10-4. Kappor N, Ciuffreda KJ, Han Y, Oculomotor rehabilitation in acquired brain injury: Arch Phys Med Rehabilitation 2004; 85; 1667-78. Sally A. Jones, Roger A, and Shinton: Improving outcome in stroke patients with visual problems: Age and Aging 2006; 35; 560-565.
Suraj Upadhyaya Pokhrel

B. Optom IXth batch Maharajgunj Campus, Institute Of Medicine Kathmandu, Nepal Email: suraj_rpj@yahoo.com
Page 58
Orbital Imaging - Dhungana
THE SIGHT
REVIEW ARTICLE
Imaging of Orbit (MRI and CT-Scan)

Surendra Dhungana
Introduction Magnetic resonance imaging (MRI) is a non-invasive method used to render images of the inside of an object. It is primarily used in medical imaging to demonstrate pathological or other physiological alterations of living tissues. MRI can generate cross-sectional images in any plane (including oblique planes). Computed Tomography (CT) is also a similar procedure but it is limited to acquiring images in the axial (or near axial) plane. However, the development of multi-detector CT scanners with near-isotropic resolution produces data that can be retrospectively reconstructed in any plane with minimal loss of image quality. While CT provides good spatial resolution (the ability to distinguish two structures at arbitrarily small distance from each other as separate), MRI provides comparable resolution with far better contrast resolution (the ability to distinguish the differences between two arbitrarily similar but not identical tissues). The basis of this ability is the complex library of pulse sequences that the modern medical MRI scanner includes, each of which is optimized to provide image contrast based on the chemical sensitivity. The fine structures within the orbit require more attention to imaging protocol then any other regions of the body to ensure the optimal diagnostic information. MRI MRI has revolutionized diagnostic imaging of orbits and its contents. With its superb soft tissue contrast and its ability to image multiple planes, MRI provides excellent rendering of orbital anatomy. Further, MRI produces image without ionizing radiation in any plane of section causing no harm to patients. Absence of bony artifact is an advantage over CT, especially in orbital apex, optic canal and parasellar regions. MRI of orbit is usually done in an axial, oblique sagittal and coronal plane in T1, T2 and fat saturated sequences. Common indications for orbital MRI are proptosis, visual THE SIGHT, Vol. 5, Issue 5, September 2009 disturbances and evaluation of orbital or ocular mass lesions. Unlike CT-scans MRI have some contraindications including claustrophobia and patients with medical or bio-stimulation implants. These implants may be implanted cardio-defibrillators (ICD), loop recorders, insulin pumps, cochlear implants, deep brain stimulators, vagus nerve stimulator, pacemakers, aneurysm clips and surgical prostheses. Interaction of the magnetic and radiofrequency fields with such objects can lead to trauma due to movement of the object in the magnetic field, thermal injury from radio-frequency induction heating of the object, or failure of an implanted device. These issues are especially problematic when dealing with the eye. Most MRI centers require an orbital x-ray be performed on anyone who is suspected to have small metal fragments in his/her eyes, perhaps from a previous accident, something not uncommon in metalworking. CT- Scan CT scanner uses X-rays, a type of ionizing radiation, to acquire its image. CT is a good tool for examining tissue composed of elements of a relatively higher atomic number than the tissue surrounding them (classically, calcium based bone visualized within carbon based flesh), such as bone and calcifications within the body, or of structures which have been artificially enhanced with contrast agents containing elements of a higher atomic number than the surrounding flesh (iodine, barium). Unlike MRI, CT also shows the soft tissues within the orbit very well and is best displaying anatomy and pathology of bony orbit. CT- scan of orbit is usually acquired in axial and coronal planes from volume scan data with potential for multiplanar reconstruction. Coronal sections should be initiated at the lateral orbital rim to lessen exposure to Page 59
Orbital Imaging - Dhungana radiosensitive lens and continued to posterior aspect of the optic canal with anterior clinoid or dorsum sella used as land marks. The axial scans should include image of entire brain, especially to include retro-orbital optic apparatus with additional retrospective magnified view of orbit. CT is particularly useful for locating foreign bodies inside the eye and usually in case of foreign objects CT- scan is done with direction of eyes in various gazes so relation of foreign body with respect to optic nerve can be known. CT has got certain advantage over MRI like patient cooperation is less crucial than in MRI, Subtle or small calcifications are well shown; artifact from eye motion is minified, inexpensive to MRI, better option for patients with metallic implants. Surendra Dhungana
Radiological Technologist Kathmandu Imaging Centre Civil Servant Hospital Email: surendra.dhungana@gmail.com
Page 60

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An annual Optometric Journal, THE SIGHT Volume 5, Issue 5 Published by: Nepal Optometry Students Society, 7th Executive

Body Copyright Nepal Optometry Students Society

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