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(writted for Nusing Sensory and perception task)




BOBBY DWI PUTERA (1511314009)



Praise be to Allah SWT who has helped his servant finish this paper with full ease.
Without his help authors may not be able to finish it. The paper is structured so that the reader
can expand the knowledge about The journal that explain Multiple Sclerosis, Vision Problems
and Visual Impairment Interventions, which i present is based on observations from a variety of
sources. This paper was prepared by the authors with many obstacles. Both coming from self-
constituent or from the outside. But with patience and especially the help of Allah, the paper
finally be resolved.

Although this paper is not perfect, but it works fairly clear detail and language that is
easily understood by the reader. Our thanks goes to lecturer of tropic and infectious diseases II
that has guided us and all those who have helped author of this paper finish. Hopefully this paper
can provide greater insight to the reader. We realize this paper has advantages and disadvantages,
constituent beg for advice and criticism. Thank you.

Padang, May 14, 2017

A. Preliminary

Multiple sclerosis (MS) is a potentially disabling disease of the brain and spinal cord
(central nervous system). In MS, the immune system attacks the protective sheath (myelin) that
covers nerve fibers and causes communication problems between your brain and the rest of your
body. Eventually, the disease can cause the nerves themselves to deteriorate or become
permanently damaged.

Signs and symptoms of MS vary widely and depend on the amount of nerve damage and
which nerves are affected. Some people with severe MS may lose the ability to walk
independently or at all, while others may experience long periods of remission without any new
symptoms. There's no cure for multiple sclerosis. However, treatments can help speed recovery
from attacks, modify the course of the disease and manage symptoms. Optic neuritis is often one
of the earliest symptoms of MS. The resulting visual incapacity in the affected eye is typically
caused by central scotoma resulting in reduced visual acuity and contrast sensitivity as well as
visual field impairments

On that basis, it was thought to create a journal review of a journal entitled Multiple
Sclerosis, Vision Problems and Visual Impairment Interventions we choose to complete the task
of review of journal about Sensory and Perception. Surely this paper is not the Word of God
therefore we try to criticize the journal both from different points of view.

1. Journal identity
Title Multiple Sclerosis, Vision Problems and Visual Impairment
Writter Francine Baril
Publish Year March, 2011

2. Journal Conclusion
a. Preliminary
Multiple sclerosis (MS) is a degenerative disease leading to progressive demyelination of the
central nervous system. The most common form is characterized by a cycle of relapses and remissions, with
defined attacks, followed by full or partial remissions. Over time, the bodys capacity to repair myelin may
diminish; neurological damage no longer reverses itself and permanent lesions remain. MS presents a
multitude of signs and symptoms, among them motor and vision impairments; cognitive and psychological
problems may also be present.
Optic neuritis is often one of the earliest symptoms of MS. The resulting visual incapacity in the
affected eye is typically caused by central scotoma resulting in reduced visual acuity and contrast sensitivity
as well as visual field impairments. In most cases, spontaneous recovery of vision occurs with visual acuity
of at least 20/40 after the recovery period, which usually lasts 6 to 12 weeks. However, visual impairment
may persist. Approximately half of individuals with MS experience a recurrence of optic neuritis during
the 10 years following the initial episode.
As they grow older, persons with MS present increasingly impaired colour discrimination, which
evolves nearly twice as fast as in MS-free individuals. MS may also cause hemianopsia; the extent of
recovery varies depending on the extent of the initial visual field impairment. The oculomotor deficit most
often associated with MS is internuclear ophthalmoplegia, which leads to diplopia. All types of nystagmus
may be encountered in individuals with MS; possible consequences are reading difficulties, oscillopsia
(stationary objects appear to be moving), blurred vision or vertigo. Ocular dysmetria and gaze paresis may
be present.
MS may cause visual impairments that require visual rehabilitation interventions. The persons
needs in terms of magnification, contrast enhancement and enlargement of the visual field should be
considered. Also to be taken into account are their physical and cognitive impairments. In conjunction with
motor and sensitivity disturbances, vision problems may jeopardize the individuals safety when they move
around, and should be considered accordingly.

b. Method
Using Descriptive research method, which is a research method that is intended to describe
the phenomena that exist, which lasted today or the past. This study does not manipulate or alter
the independent variables, but describes a condition as it is. The depiction of conditions can be
individual or use numbers. (Sukmadinata, 2006: 5)
Descriptive research, can describe a situation only, but can also describe the state in the
stages of its development, such research called developmental studies (Developmental Studies).

c. Pengolahan dan Analisis Data

The research data collected using ordinal scale is calculated using percentage to facilitate
comparison, then categorized to be good, less and just follow the normative distribution, that is:
1) good (80%), 2) enough (60-80%), and 3) less (<60%). Meanwhile, the data are intervals and
ratios such as case data of patients suffering from MS and get visual acuity. The quantitative data
collected in this study, processed using the average value, distribution, and percentage.


1. Etiology and pathogenesis

Multiple sclerosis is regarded as a demyelinating inflammatory disorder of the central
nervous system (brain, spinal cord and optic nerve). Myelin forms a sheath around certain nerve
fibres. In the initial stages of the disease, an attack (also called a flare-up or exacerbation) is
characterized by inflammation of the myelin along the nerve fibres (axons), which damages or
halts nerve impulses. The healing process results in remission (remyelination), which may be full
or partial. Over time, the organisms capacity to repair myelin may diminish; neurological damage
is no longer reversed and permanent axonal lesions caused by inflammation then occur.
Between 80% and 85% of persons with MS start by presenting a cyclical form of the illness
(relapsing-remitting). Clearly defined acute attacks are followed by full recovery or with sequelae
and redidual deficit upon recovery. Each attack is followed by full or partial remission, which may
last for months or even years. In people with the cyclical form of MS, during the ten years
following diagnosis, some 50% will develop the secondary progressive form, with progression of
the disease with or without occasional relapses, minor remissions and plateaux. The remaining
10% to 15% of cases will experience a slow accumulation of neurological problems from the
outset, with occasional plateaux and temporary minor improvements (primary progressive form).
2. Optic neuritis
Optic neuritis or the presence of vision symptoms is the first sign of MS in 14% to 27% of
cases. Optic neuritis is a demyelinating inflammation of the optic nerve, characterized by reduction
or loss of vision in one eye that progresses for about a week. The optic nerve is affected in some 2
out of 3 MS cases (Warner & Lessell, 1994, cited by Gizzi & Kastner, 2000). The resulting visual
impairment in the affected eye is typically caused by central scotoma, often in the temporal field.
Optic neuritis also causes a total or relative afferent pupil defect1. The resulting loss of visual
acuity (VA) is very variable.
A study by the Optic Neuritis Study Group (1991) found that an equal proportion of 448
subjects with a first acute episode of optic neuritis (within the last 8 days) had mild (35%),
moderate (29%) or severe (36%) loss of visual acuity. A variety of visual field deficits is also
present and optic disc swelling is often observed. Vision loss is usually accompanied by ipsilateral
pain in or behind the eye that is worse during eye movements, whether or not the optic disc appears
normal or swollen. Because the visual field deficit tends to involve the macula, colour perception
and contrast sensitivity impairment are common and may be permanent. Phosphenes (luminous
impression occuring when the retina undergoes nonluminous stimulation) may be precipitated by
eye movements. In addition, because having only one eye affected results in asymmetry between
the eyes in the perception of luminosity and contrast, the optic neuritis may cause an illusion of
depth when the person looks at a moving object (Pulfrich effect); they may, for example, be
somewhat disoriented in moving traffic. In 90% of cases of optic neuritis, MS-related or not,
spontaneous recovery of vision usually occurs with visual acuity of at least 20/40 after the recovery
period. This period generally lasts 6 to 12 weeks though improvements may be observed up to 6
months or even a year after onset of the episode. In some cases, however, there is no improvement
in vision.
The long-term risks of recurring optic neuritis and permanent damage are twofold higher
in people with MS than in others. In a follow-up study by the Optic Neuritis Study Group (2004),
48% of the 148 individuals with MS who had experienced a first episode of optic neuritis 10 years
earlier, suffered a recurrence of optic neuritis in one eye during this period (16% in the eye first
affected, 19% in the other eye and 13% in both eyes). During the follow-up examination (10 years
after the initial episode), a high proportion had abnormal visual function in the eye first affected,
in terms of visual acuity (40%; < 20/20), contrast sensitivity (39%; < - 3.00 db). Loss of visual
function was also measured in the other eye, for 22% to 26% of the subjects, depending on the
visual function assessed. This same study showed that a visual impairment may result from
episodes of optic neuritis, as shown by the fact that among the total 319 subjects with and without
MS, visual acuity in the affected eye was between 20/40 and 20/200 in 5% of cases and lower than
20/200 in 3%. Symptoms may briefly recur in the affected eye when body temperature rises (e.g.
during heat exposure, vigorous exercise, hot bath). However, this is rare. Medical treatment of
optic neuritis may shorten recovery time but has no impact on the end result, i.e. the extent of
possible sequelae.

3. Possible drug side-effects on vision

Certain medications used to treat MS symptoms may have side-effects that affect vision.
Gizzi & Kastner (2000) cite a few examples: anti-spasmodics may cause gazeevoked nystagmus
or slowing of visual pursuit; medication for bladder problems may cause blurred vision; treatment
with tricyclic antidepressants may cause pupillary accommodation problems; anti-fatigue
medication may be associated with nystagmus.
4. Conclusion

Vision problems are common in people with multiple sclerosis but they generally recover
quite well following a flare-up. However, as attacks accumulate, vision and oculomotor problems
may persist. Adding to the physical, cognitive and psychological symptoms, they may further
complicate the overall picture and contribute to a significant decline in functional capacity and
quality of life. Vision rehabilitation may then be required. When we assess an individual with MS
and establish the intervention plan, the wide diversity of possible symptoms make it critically
important to use a holistic, interdisciplinary approach in order to address the persons needs. This
will ensure that interventions achieve optimal impact.

This journal Multiple Sclerosis, Vision Problems and Visual Impairment
Interventions very helpful in health education institutions and the health world itself. Given the
rarity of research that leads to discussion of the effects of multiple sclerosis on visual impairment.
As for us as a reviewer will try to outline the advantages and disadvantages of this journal article:

1. Advantages
The advantages of this journal are to explain in detail about multiple sclerosis (MS) and its
effect on the central nervous system, especially visual acuity and deficit of ocular and oculomotor
system, both qualitatively and quantitatively based on MS patients. As well as interventions to
visual impairment as a result of MS. The journal also features quotes from sources that can be used
to find out more details about related matters. Psychological and cognitive impacts of MS and
possible consequences for vision rehabilitation are also described in this journal.

2. Disadvantges
The disavantages of this journal is that it does not explain in detail the therapy for the
healing of Ms itself. The author also does not explain clearly about the related research that can be
used as a reference in handling and preventing MS in the future.


1. Conclusion
From the above review, it can be concluded that:
a. Vision problems are common in people with multiple sclerosis but they generally recover quite
well following a flare-up
b Adding to the physical, cognitive and psychological symptoms, they may further complicate the
overall picture and contribute to a significant decline in functional capacity and quality of life.
c. When we assess an individual with MS and establish the intervention plan, the wide diversity of
possible symptoms make it critically important to use a holistic, interdisciplinary approach in order
to address the persons needs. This will ensure that interventions achieve optimal impact.

2. Suggestion
Review provides suggestions addressed to this journal, as for the inputs are as follows:
1. It will be helps if the authors include research data ever done related to MS cases.
2. There should be an explanation of therapies that can be done with MS patients, not just about
visual impairment

Baril, Francine. "Multiple sclerosis, vision problems and visual impairment

interventions." (2011).
(writted for Nusing Sensory and perception task)




BOBBY DWI PUTERA (1511314009)



A. Tear Supplementation: Lubricants

The term artificial tears is a misnomer for most products that identify themselves as such,
because they do not mimic the composition of human tears. Most function as lubricants, although
some more recent formulations mimic the electrolyte composition of human tears (TheraTears
[Advanced V ision Research, Woburn, MA]). The ocular lubricants presently available in the
United States are approved based on the US Food and Drug Administration (FDA) monograph on
over-the-counter (OTC) products (21 CFR 349) and are not based on clinical efficacy. The
monograph specifies permitted active ingredients (eg, demulcents, emulsifiers, surfactants, and
viscosity agents) and concentrations, but gives only limited guidance on inactive additives and
solution parameters.
Certain inactive ingredients that are used in artificial tears sold in the US (eg, castor oil in
Endura [Allergan, Inc., Irvine, CA] and guar in Systane [Alcon, Ft Worth, TX]) are not listed
in the monograph. It is difficult to prove that any ingredient in an ocular lubricant acts as an active
agent. If there is an active ingredient, it is the polymeric base or viscosity agent, but this has proved
difficult to demonstrate. This is either because it is not possible to detect the effects or differences
in clinical trials with presently available clinical tests or because the currently available agents do
not have any discernable clinical activity beyond a lubrication effect.
Although certain artificial tears have demonstrated more success than others in reducing
symptoms of irritation or decreasing ocular surface dye staining in head-to-head comparisons,
there have been no large scale, masked, comparative clinical trials to evaluate the wide variety of
ocular lubricants. What isthe clinical effect of ocularlubricants or artificial tears? Do they lubricate,
replace missing tear constituents, reduce elevated tear film osmolarity, dilute or wash out
inflammatory or inflammation-inducing agents? Do they, in some instances, actually wash out
essential substances found in normal human tears? These questions remain to be answered as more
sensitive clinical tests become available to detect changes in the ocular surface.
The foremost objectives in caring for patients with dry eye disease are to improve the
patients ocular comfort and quality of life, and to return the ocular surface and tear film to the
normal homeostatic state. Although symptoms can rarely be eliminated, they can often be
improved, leading to an improvement in the quality of life. It is more difficult to demonstrate that
topical lubricants improve the ocular surface and the tear film abnormalities associated with dry
eye. Most clinical studies fail to demonstrate significant correlation between symptoms and
clinical test values or between the clinical test values themselves.It is not unusual for a dry eye
with only mild symptoms to show significant rose bengal staining. Until agents are developed that
can restore the ocular surface and tear film to their normal homeostatic state, the symptoms and
signs of dry eye disease will continue.
Ocular lubricants are characterized by hypotonic or isotonic buffered solutions containing
electrolytes, surfactants, and various types of viscosity agents. In theory, the ideal artificial
lubricantshould be preservative-free, contain potassium, bicarbonate, and other electrolytes and
have a polymeric system to increase itsretention time. Physical properties should include a neutral
to slightly alkaline pH. Osmolarities of artificial tears have been measured to range from about
181 to 354 mOsm/L. The main variablesin the formulation of ocular lubricants regard the
concentration of and choice of electrolytes, the osmolarity and the type of viscosity/polymeric
system, the presence or absence of preservative, and, if present, the type of preservative.
B. Tear Retention

While the concept of permanently occluding the lacrimal puncta with cautery to treat dry
eye extends back 70 years,49 and, although the first dissolvable implants were used 45 years
ago,50 the modern era of punctal plug use began in 1975 with the report by Freeman. Freeman
described the use of a dumbbell-shaped silicone plug, which rests on the opening of the punctum
and extends into the canaliculus. His report established a concept of punctal occlusion, which
opened the field for development of a variety of removable, long-lasting plugs to retard tear
clearance in an attempt to treat the ocular surface of patients with deficient aqueous tear
production. The Freeman style plug remains the prototype for most styles of punctal plugs.

C. Tear Stimulation: Secretogogues

Several potential topical pharmacologic agents may stimulate aqueous secretion, mucous
secretion, or both. The agents currently under investigation by pharmaceutical companies are
diquafosol (one of the P2Y2 receptor agonists), rebamipide, gefarnate, ecabet sodium (mucous
secretion stimulants), and 15(S)-HETE (MUC1 stimulant). Among them, a diquafosol eye drop
has been favorably evaluated in clinical trials. 2% diquafosol (INS365, DE-089 [Santen, Osaka,
Japan]; Inspire [Durham, NC]) proved to be effective in the treatment of dry eye in a randomized,
double-masked trial in humans to reduce ocular surface staining. A similar study demonstrated the
ocular safety and tolerability of diquafosol in a double-masked, placebocontrolled, randomized
study. This agent is capable of stimulating both aqueous and mucous secretion in animals and
humans. Beneficial effects on corneal epithelial barrier function, as well as increased tear
secretion, has been demonstrated in the rat dry eye model. Diquafosol also has been shown to
stimulate mucin release from goblet cells in a rabbit dry eye model.

D. Biological Tear Substitutes

Naturally occurring biological, ie, nonpharmaceutical fluids, can be used to substitute for
natural tears. The use of serum or saliva for this purpose has been reported in humans. They are
usually unpreserved. When of autologous origin, they lack antigenicity and contain various
epitheliotrophic factors, such as growth factors, neurotrophins, vitamins, immunoglobulins, and
extracellular matrix proteins involved in ocular surface maintenance. Biological tear substitutes
maintain the morphology and support the proliferation of primary human corneal epithelial cells
better than pharmaceutical tear substitutes.109 However, despite biomechanical and biochemical
similarities, relevant compositional differences compared with normal tears exist and are of
clinical relevance. 110 Additional practical problems concern sterility and stability, and a labor-
intensive production process or a surgical procedure (saliva) is required to provide the natural
tear substitute to the ocular surface.

E. Anti-Inflammatory Therapy

Disease or dysfunction of the tearsecretory glandsleads to changes in tear composition,

such as hyperosmolarity, thatstimulate the production of inflammatory mediators on the ocular
surface.31,121 Inflammation may, in turn, cause dysfunction or disappearance of cells
responsible for tear secretion or retention. 122 Inflammation can also be initiated by chronic
irritative stress (eg, contact lenses) and systemic inflammatory/autoimmune disease (eg,
rheumatoid arthritis). Regardless of the initiating cause, a vicious circle of inflammation can
develop on the ocular surface in dry eye that leads to ocular surface disease. Based on the
concept that inflammation is a key component of the pathogenesis of dry eye, the efficacy of a
number of anti-inflammatory agents for treatment of dry eye disease has been evaluated in
clinical trials and animal models.

F. Essential Fatty Acids

Essential fatty acids are necessary for complete health. They cannot be synthesized by
vertebrates and must be obtained from dietary sources. Among the essential fatty acids are 18
carbon omega-6 and omega-3 fatty acids. In the typical western diet, 20-25 times more omega-6
than omega-3 fatty acids are consumed. Omega-6 fatty acids are precursors for arachidonic acid
and certain proinflammatory lipid mediators (PGE2 and LTB4). In contrast, certain omega-3
fatty acids (eg, EPA found in fish oil) inhibit the synthesis of these lipid mediators and block
production of IL-1 and TNF-alpha

G. Environmental Strategies

Factors that may decrease tear production or increase tear evaporation, such as the use of
systemic anticholinergic medications (eg, antihistamines and antidepressants) and desiccating
environmental stresses (eg, low humidity and air conditioning drafts) should be minimized or
eliminated. 180-182 Video display terminals should be lowered below eye level to decrease the
interpalpebral aperture, and patients should be encouraged to take periodic breaks with eye
closure when reading or working on a computer. 183 A humidified environment is recommended
to reduce tear evaporation. This is particularly beneficial in dry climates and high altitudes.
Nocturnal lagophthalmos can be treated by wearing swim goggles, taping the eyelid closed, or