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NOSS 07/08: At a glance

Nepal Optometry Students Society Ravindra Adhikary The Secretary, NOSS Former body dissolved, new committee of 6 was reframed on 20th September 2007 after cutthroat poll at the 7th general assembly of NOSS. The 7th body comprised Gopal Bhandari as the president, Navinraj Joshi as the vice-president, Ravindra Adhikari as the secretary, Himal Kandel as the treasurer, Raju Kaiti and Sonisha Neupane as the members and later Ashutosh Jnawali appointed to member from the freshers. The hand over of rights, responsibilities and assets took place after 1st consecutive week. Hereunder are some of the endeavors and events worth to publicize during our 1 year long tenure:
3rd -7th Oct. 2007: 9 optometry students along with 3 instructor optometrists delightfully participated on 16th Asia Pacific Optometry Congress held in Goa, India. The opportunities they got after sharing experiences with abroad students and scrutinizing the global scenario of optometry worldwide is sublime to make the history of goodwill. We put our efforts to give continuity to the distribution of the 3rd edition of THE SIGHT throughout Nepal (All eye hospitals & zonal hospitals) and all departments of TUTH. Publication, pasting and stitching of Dristi wall magazine at various places of TUTH premises. We have been forwarding each issue to every graduated optometrists, optometry students, relevant eye health personalities, eye hospitals of Nepal and various organizations abroad via email. 11th Oct.2007: Initiative to little optometry program; 1st phase with 74 students of 4 schools of the valley. We successfully delivered eye health education and vision training by seminar, group discussion and demonstration. Website reformation, giving continuity and intermittent updates www.optometrynepal.org.np 8th Nov 2007: conducted farewell program to erstwhile instructor optometrist Mr. Asik Pradhan who was all set to go abroad for employment opportunities. 3rd Week Nov. 2007: Entry of 7 new members (Ashutosh, Baburam, Jewel, Pratik, Raman, Sarita, Subash) to our family-Introductory program. 28th Dec 2007: School eye screening of 300 students at Prabhat Higher Secondary School, Bhaktapur. 8th Feb 2008: Welcome cum farewell ceremony to new comers and graduates respectively trendsetting the informal program for the first time. 24th Feb 2008: NOSS & BPKLCOS jointly organized farewell program to the senior instructor optometrist Mr. Prakash Paudel who was on departure to UNSW, Australia in pursuit of Ph.D 4th Week March 2oo8: Student representation and letter submission to the deans office pressurizing for the prompt publication of the final exams results.

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2nd Week April 2008: We succeeded to achieve computer and LCD from the campus after onerous attempts. 19th-21st April 2008: Eye screening camp at hinterland Bethan-9, Ramechhap whereby 300 locals benefitted. 25th May 2008: After a long relentless exercise we were able to carry out a multirepresentative special round table talk program reiterating the existing problems of the optometry program with a due help of the Campus. Not an onrush pace it could take, though was fecund ultimately in myriad ways. 6th June 2008: As a trail blazer, NOSS conducted the First Intra-optometric Quiz contest, which was a head start celebration of 1st glorious decade of optometry in Nepal. 11th July 2008: School screening of 500 children at Rising Rays school, Putalisadak. 15th July-2nd Aug 2008: Fever of 1st glorious decade celebration hit the zenith when we launched Opto-Sports Series 2008 inclusive of cricsol, futsol, badminton, chess, table-tennis, tug of war and the scrabble. 18th July 2008: NOSS and Ophthalmology residents jointly organized an informal experience sharing program on teachers day with our reverend teachers. 19th July 2008: Eye health screening of elderly women at Matatirtha Asylum in association with NMSS. 25th July 2008: NOSS & BPKLCOS organized farewell program to instructor Mr. Sanjeeb Mishra well wishing for his study abroad. Eye health screening programs: o o o o o 2nd Aug 2008: 312 school children with few locals screened at Amar Jyoti Secondary school, suichatar. 3rd Aug 2008: 21 deaf students screened at CBR, Bhaktapur. 5th Aug 2008: 350 children screened at Nagarjun Valley School, Banasthali. 9th Aug 2008: 200 orphans screened in Gurje, Nuwakot under Umbrella Foundation.) Numerous eye health screenings: Nile stream school (Sanepa), Mother Care preschool center (Baluwatar), Genuine Secondary school (Bhaktapur), Adarsha deaf School (Banepa), Down Syndrome Association of Nepal, Kapurdhara (C/O Nabin Paudel rsch), Cerebral Palsy Center, Dhapakhel (C/O Sanjay Marasini rsch), Naxal deaf school (C/O J.N. Bist rsch) We will soon launch 2nd phase of Little Optometrists program with separate banners and pads.

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11th Aug 2008: introductory seminar on Optometry as an emerging Career at NAME to prospective students. 29th Aug 2008: As a grand celebration of the 1st glorious decade of optometry in Nepal, NOSs in association with Nepalese Association of Optometrists organized a ceremony comprising the scientific paper presentations by eye health care professionals. 9th Sept 2008: Publication of The Sight, 4th Volume and release along with the release of the annual compilation of Dristi Monthly Wall Magazine.

Financial Aspect:
Funds collected for The Sight a major source (ads from optical +aids from Campus +BPKLCOS) Sale: B. Optom entrance preparation guide, Brock-string vision therapy kits as prescribed from orthoptic unit of BPKLCOS, NOSS T-Shirts, Low vision bold line copy, Pinholes. Membership levies from new comer optometry students. Plan: Megabucks can be collected from school screenings and entrance crammer classes, selling CDs about handle and care of contact lens from CL unit, BPKLCOS to interested patients, selling Dristi magazine, from the advertisements in our official website, public awareness program and eye health campaigning collaborating with NGOs, INGOs.

Invited Article LEARNING PROBLEMS ARE BRAIN PROBLEMS: WHAT NEUROLOGY, OPTOMETRY, EDUCATION, PSYCHOLOGY AND PSYCHIATRY HAVE IN COMMON. Merrill D. Bowan, O.D.

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THE BRAIN, OPTOMETRY, AND LEARNING What do optometry, neurology; education, psychology and psychiatry have in common? We all deal with the BRAIN. The brain gets most of its information through the eyes and the cognitive sense called vision. Vision as we are discussing it here is dynamic and very different from sight, which is essentially a static response. Humans are truly visual beings: more than eighty percent of what we know has come through our eyes and vision, more than fifty percent of the anatomy of the brain, and two thirds of its waking electrical activity is dedicated to vision and visual perception. If a persons visual processing is inefficient, then optometrists are in a unique position to enhance learning and working ability. Learning is from experience and the experts have discovered that the most effective learning involves sensorimotor encounters. Of importance to optometrists, the majority of those involve visual-motor guidance. In ways that we poorly understand, the brain sorts and orders the data and forms it into what are called percepts, which are then grouped into response patterns that learning specialists call operations. The brain uses these learned operations to act upon and react to the world. What psychologists and psychiatrists call Mind and Person may be considered to be built upon our percepts, for the most part. The five professions (Neurology, Optometry, Education, Psychology and Psychiatry) all deal either directly and/or indirectly with the core set of processes of the brains daily physiological and behavioral operation, that is to say: input, association, and output. It is fair to say that a brain that isnt learning is a brain that needs to change in some way. Optometrists can play a major role in the changing of a childs brain.

PERCEPTION, PERFORMANCE, AND PERSONALITY

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When a childs academic performance and grades are off, its because the brain is off in some way or other. School grades are actually one simple way by which we can measure brain function but most professionals dont think of this especially teachers, who often undervalue themselves and their role but its no less true. Martha Denckla, a neuroscientist, said, Every teacher is a brain surgeon making little dendrite sprouts and connect(ing) up neurons,
1

One failure of many professionals is in recognizing that the phenomenon of perception is as much or more a neurophysiological process as it is a psychological process, though it has elements of both. As will be discussed later, a persons environment has an impact on not only their learning, but surprisingly, also on the brains anatomy. Visual therapy specialists have informally speculated this upon for years, and current neural research and clinical investigations support this clinical impression. Further research will elaborate the mechanisms, many of which appears to center around stress and coping. Perceptions affect cognitive associations, which in turn affect relationships in the brains understanding of its environment both the physical world and the social/emotional one, as well. Social relationships help to mold much of our ego concepts. Virtually all rational problem solving will suffer when perceptual problems exist. Because of the central nervous system interactions, perceptual problems wind up creating not only learning problems but interpersonal and ego problems as well. This is not to say that all psychological problems are the result of perceptual difficulties. However, A.M. Skeffington, the patriarch of behavioral optometry, often said in his lectures: A person insecure in his visual state will be a person insecure in his ego state. HOW CAN THE BRAIN BE CHANGED? There are five ways by which we can influence the brain to make it change:
1.

Surgically: as in Parkinsonism, epilepsy, and unrelenting depression.

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2.

Chemically: with medications (Ritalin, Dexedrine, Adderall, Stratera,

Vyvanse, Prozac, Valium, antipsychotics, etc.). This is the most common avenue of deliberate intervention.
3.

Retraining: formal education, motor rehabilitation, and experiential

instruction. This is the basis of daily change in our brains. It is normally a slow, deductive and inductive, often random process that can be applied in a structured, directed way. Thats when we call it teaching. (All educational strategies are rehabilitative, shaping brain circuitry.)
4.

Biofeedback: changes of physiological activity by internal

modification of signals in response to real-time information. (This is actually a retraining, but it is a self-generated, conscious neurophysiological reorganization.)
5.

Optically: via lenses, prisms and filters. They:

A. B.

Change the visual-motor responses to ones space world; Change the ratio of action between the voluntary and Change the ratio of action between the sympathetic and Change the signal quality, which may alter the rate at

involuntary nervous systems;

C.

parasympathetic nervous system branches; and,

D.

which the brain processes visual input (like changing the clock speed in a computer). Optometrists, approaching the individuals visual problems behaviorally, routinely employ three of the five avenues of brain change. They train and retrain, use optics, and develop biofeedback skills. Understand that visual problems do not cause learning problems as such. No credible authority has ever said so.2 Yet, visual problems can create functional difficulties that can become a collateral part of learning problems. Most of the time when there are visual problems, the effect is an indirect one the student cannot sustain learning activities because of visual distress and in this way, visual problems can mimic attentional problems. (ADD/ ADHD).

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Not many educators or other professionals take into account that reading actually occurs at two levels: decoding alone, and decoding with comprehension. We have all experienced reading while we were fatigued and have gotten to the bottom of a page without any comprehension of what was read yes, decoding occurred, but no comprehension did. Visual problems again, not sight problems often affect the underachieving student in the same way. They make it appear as if a primary problem in attentional ability were present, when in fact, the problem may be a secondary effect of visual dysfunction, or from some other contributing concerns: sensory, affective, emotional, medical, or nutrition. This present discussion is limited to vision and sensorimotor concerns, the other areas need to be dealt with by referral for evaluation by specialists sensitive to the classroom needs from their respective disciplines. OPTOMETRIC INTERVENTIONS Lenses and prisms, (and filters, under more rare circumstances) affect the perception of space, they alter the inborn response of the nervous system, and they reduce the impact of the element of time upon the activities of the visual system. The element of time is a commonly overlooked factor in the genesis of disease conditions, and visual dysfunction is no exception. The optometrist who is looking at the whole child needs to understand how long that student is able to sustain his or her visual attention to permit adequate perception and learning of the task at hand. Ongoing research and clinical experience now indicates that visual therapy, low plus, and prism affects the Parasympathetic Nervous System directly.3,4 Visual-motor perception, farsightedness, and suppression of vision in one eye have all long been shown to relate negatively with school performance.5-7 The ability of perceptual therapy to remediate academic problems has been known for some time to those who have looked for the information8; orthoptic training has been shown to improve reading in at least one prospective study9; and visual therapy has been shown to affect self-perception10. 13 | P a g e

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PSYCHOLOGICAL CONCERNS We know that children with learning difficulties have a higher prevalence of depression and other emotional problems.11 One study found that learning disabled students were more often depressed specifically about their school environment than a control population, whose concerns were outside the school scene.12 Additionally, schizophrenics have poorer eye motilities and have dramatically altered spatial perception when compared to the general population13. There are case reports in the popular press that discuss the effects of visual rehabilitation in certain dramatic psychiatric situations.14, 15 Mental abuse and emotional stress are known to have direct structural effects on an area of the brain that affects learning and memory (the hippocampus).16, 17 Problems may arise from perceptual or sensorimotor processing problems either directly or indirectly. Therefore a health clinician may be consulted for any of these reasons, either for psychological measures, behavioral intervention, or both. CAN LEARNING DISABILITIES BE REMEDIATED? Learning disabilities CAN be helped, if not actually cured.18 All barriers to learning need to be addressed: evaluation for sensory operating problems, emotional concerns, physical health needs (including a childs nutritional state), and/or poor academic readiness, may be appropriate. Two areas of great benefit in rehabilitation are, one, retraining of sensorimotor skills; and, two, binocular visual therapy. Problems in these last two areas may affect one-half to two thirds of children with learning problems and a validated curriculum is available which results in rapid remediation of perceptual skills.8 Teachers need to understand the different styles of learning, how to teach to strength learning modes and how to recognize the symptoms of visual and perceptual dysfunction. They can then begin classroom accommodations and refer those students with learning skills problems for assessment and rehabilitative care. These measures are stop-gap only, though, for the use of visual-auditory-kinesthetic-tactual (V-A-K-T) 14 | P a g e

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strategies and teaching to strengths used alone have yet to be demonstrated to have positive outcomes over the long run.19 Therapeutic educational techniques may be appropriate as well. OPTOMETRY AND LEARNING, REVISITED Behavioral, developmental, or neuro-developmental no matter what its called optometric retraining (using lenses, prisms, filters and biofeedback) has had arguably the greatest clinical impact on learning problems out of the five professions with the five intervention strategies. Optometric visual and perceptual therapy can be a powerful healing tool in many, many learning problems. It results in the most rapid response, frequently in mere weeks, sometimes in months. The concerned optometric practitioner will want to consider expanding the scope of his or her practice to include visual therapy. REFERENCES
1. 2.

TV interview for Dana Corporations Exploring Your Brain, 1998. Wold, R; Vision and Learning Update, Tape Series, Am. Optom. Bowan MD. The Visual Aliasing Syndrome: addressing the pattern

Assn., 1973.
3.

distress of text. (In review: conditionally accepted for publication. Optometry.)

4.

Bowan MD. Visual Convergence Therapy as a Vagal Maneuver: an Helveston, E; The Draw-a-Bicycle Test, J Ped Ophthalmol & Strab Rosner J, Rosner J; The Relationship Between Moderate Hyperopia

unexpected palliative for vagally-related issues. (In review.)

5.

22(1), 917-919, 1985.

6.

and Academic Achievement: How Much Plus is Enough?, J Am Optom Assoc, 1997 Oct; 68(10):648-650.
7.

Benton, C; in Dyslexia : Diagnosis and Treatment of Reading

Disorders, Keeney and Keeney , Eds., CV Mosby, NY 1968.

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8.

Rosner J; The Development and Validation of an Individualized

Perceptual Skills Curriculum, LRDC Publication 1972/7, U of Pittsburgh, 1973.

9.

Atzmon D, Nemet P, Ishay A, Karni E; A Randomized Prospective

Masked and Matched Comparative Study of Orthoptic Treatment Versus Conventional Reading Tutoring Treatment for Reading Disabilities in 62 Children, Binoc Vis Eye Musc Surg Qtrly 1993; 8:91-108.
10.

Bachara, G, Zaba, J; Psychological effects of visual training, Walzer S, Richman J,; The Epidemiology of Learning Disorders, Abrams J; An Analysis of Learning Disabilities and Childhood

Academic Therapy, Vol. XII, No. 1, Fall 1976.

11.

Pediatric clinics of North America, 20(549-566) 1973.

12.

Depression in Pre-adolescent Students, doctoral dissertation, Indiana University of Pennsylvania, 1990.

13.

Flach, F, Kaplan, M Bengelsdorf H, Orlowski B, Friedenthal S,

Weisbard J, Carmody, D; Visual Perceptual Dysfunction in Patients with Schizophrenic and Affective Disorders Versus Control Subjects, J Neuropsych, 1992, Fall, 4(4) 422-427.
14.

Flach F; Resilience, Fawcett Columbine, NY, 1989.

BCVA:
Then

Then and now!

Dr. N.D.Joshi, MBBS,F.R.C.Opth(Eng),F.A.C.S.(USA) F.I.C.S.D.O(Lond)

It happened about fifty years ago. I was in charge of the eye unit at the Bir Hospital and also had my private clinic at Basantapur. On occasion I had a VVIP patient visit my clinic for consultation. I had to refract and prescribe a new pair of glasses. I went through the routine examination and made out a prescription for a new pair of glasses16 | P a g e

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compound fairly high myopia with astigmatism and addition for near bifocal pair of glasses and he wanted them fitted in this old frame custom designed tortoise shell frame from London. I had to have him know that it would be advisable to have them done abroad. Prescription of glasses could not then be dispensed correctly by the available opticians. He came back after a few days to have the newly obtained pair of glasses checked. He had found them comfortable and could see a lot better. He wanted to be checked and confirmed. It was done perfectly .On enquiry I was told that he had them done by an optical shop in India .I knew the optical shop and have had dealing with the people- British firm well established and reputed. Then came the story of how he had been had in getting this pair done. He was in a social party meet one evening and happened to have mentioned that he had been to see me and had a new pair of glasses prescribed and also that he had been advised that this could not be done by local optical shop and was wondering how to get it done. One of the guests in the crowd offered to help and asked for the prescription which he had with him and handed it over to the person. Few days later the person concerned brought the glass fitted in his old tortoise shell frame. He was so happy to have done so promptly and tried them out and found very satisfactory. He asked the people to let him know how much it cost and thanked him profusely. He was so grateful and yet was not prepared for what happened afterwards. The person brought out a pile of bills which included air tickets from Kathmandu- Calcutta Kathmandu and two night five star hotel bill and transport fares plus the cost of the lenses which amounted to a fair amount lot more than the usual cost of a pair of glasses. He could not believe and was completely dumfounded. He knew he has been had and yet could not do anything but to pay the amount. He looked at me .What could I say. That was then more than a century ago.

And now

Things have changed a lot since. Today there are educational institutions for training in most of the medical specialties including allied ophthalmic medical courses. Now there are eye hospitals and clinics scattered all over the country. Doctors study MD in Ophthalmology and pass out in less numbers every year and almost all the eye hospitals and clinics are manned by specialists qualified from our own universities and trained in the ophthalmic subspecialties. Medical graduates from countries abroad come here for MD in ophthalmic speciality. Things have indeed changed a lot for better. Optical shops are available in every corner of the streets. Prescription glasses are filled and dispensed in hundreds every day. Computerized eye examinations- auto refractor are offered by some of these establishments. People are impressed by the mention of computerized examination .Graduate optometrists pass out and also quite a few ophthalmic assistance qualify every year. It is the high time to improve the quality and standard of prescription and lens dispensing. In these days of Laser refractive surgery services available in the country. Phacoemulsification s with home made foldable intraocular lens implants are routine procedures in almost every eye hospitals of the country. And 17 | P a g e

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yet conventional prescription lenses are not of proper standard which could have a lot better. Most of the optical shops are disappointingly under equipped for proper fitting and dispensing. Routine prescription lenses are not centered properly, bifocal segments heights are misplaced and trifocals and multifocal are hardly ever made. They need special fitting gadget and need to be precisely dispensed so that wearing glasses is comfortable and easily tolerable. Lenses dispensed inappropriately can cause permanent damage to eyesight particularly in young growing children. Frames should well be fitted and skull temple arms not too long and not bent at odd angles with ends not extended beyond ear lobe looking like earrings. They should be comfortable and sitting comfortably on the nose bridge to meet the individual need. Lenses need also to be legally recommended thickness and quality and proper material selection. Polycarbonate is the material of choice for the pediatric patients because they are four times more resistant to breakage than any other lenses. Plastic CR-39 and hardened glass lenses are not impact resistance nor scratch resistance. Quality control of eyewear lenses should be enforced like in other products. Most of the prescriptions filled lenses seem to have come from the one workshop including the ones from inside hospital premises. It is desirable that the lenses dispensed by optical establishment from inside the institution are better and properly done. It is time to make a move towards improving the quality of services standard in this particular field of lens dispensing. Optical shops are far too many. New optical shop establishment should have registration control and rules and regulations should be set for license to be issued and this should be under supervision of concerned health authorities. A lot more is still to be desired in the quality of optical dispensing services. Prescription lenses dispensed not correctly can cause more than harm than good. It is high time to have to have the services of qualified dispensing opticians made available. Best glasses are of no value if they are never worn all the efforts towards making patients have best corrected visual acuity would be of no benefit if dispensing of prescription lenses fail.

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Refractive and Primary Eye Care Services: Burden and the Solution
Prakash Paudel, B.Sc., B.Optom., FIACLE, FLVC School of Optometry and Vision Science University of New South Wales Sydney, Australia The astounding facts came up regarding the global magnitude of refractive error once the World Health Organization revealed that beside 161 million people who are visually blind from eye diseases[1], another 153 million people have significant vision impairment due to uncorrected refractive error[2]. At least another 517 million people are visually impaired as a result of uncorrected presbyopia[3]. It is also estimated that 300 million people who are in need of spectacles are not wearing spectacles[4] because refractive services are not easily accessible to them or they are not willing to pay or afford a pair of glasses. The interesting fact is that 75% of all blindness is either avoidable or treatable[5] and 90% of avoidable blindness occurs in developing countries[6]. This is ten times more likely for people in developing countries than those in the developed world[4]. There is direct or indirect link between blindness and poverty. Blindness or a visual impairment can keep people from going to school, working, and providing support for their families. Blindness, known as disability, often leads to unemployment which in turn leads to loss of income, higher levels of poverty and hunger and low standards of living. Frick and Foster estimated the costs of global blindness and low vision at $42 billion in 2000 with projected rise up to $110 billion by 2020 if estimated with the same prevalence[7]. The economic burden of blindness in India was estimated at US$4.4 billion using the cost-of-illness methodology and was estimated at US$77.4 billion using the cumulative loss over the lifetime of the blind[8]. As the magnitude of blindness due to refractive error is significant in developing nations, any strategies to combat avoidable blindness must take into account the socio-economic conditions within which people live. As South-East Asian countries contribute nearly one fourth population of the world[9], the economic burden of blindness and visual impairment is significantly high in this region. Almost one-third of total blind people in world live in South-East Asia region[10]. The burden is highest in India where one-fifth of the worlds visually impaired people (i.e. nearly 6.7 million people) are blind[1]. As of 1981 national blindness survey, Nepal 19 | P a g e

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has 0.185 million blind people[11] with an unseen annual increase in blind people. The major causes of blindness in this region are cataract, uncorrected refractive error and corneal diseases etc. The major barriers to services are identified as shortages or insufficient number of human resources, infrastructures, transportation facilities and lack of awareness. Many developing countries today suffer from severe staff shortages and/or misdistribution of health personnel[12]. The misdistribution of personnel has resulted in longstanding global inequalities. Asia, where half the world's population live, has access to only about thirty percent of the world's health professionals[12]. The significant proportion of eye care practitioners are mostly found concentrated in developed countries and many do not serve in the country of origin or developing countries. In addition, these personnel in both developed and developing countries are usually concentrated in urban areas. For example, 80% of human resources are concentrated in urban areas in Asian countries[13, 14] Rural-to-urban brain drain is also compounded by public-to-private brain drain resulting into inaccessible services for the people living in rural and remote communities. Nepal, with a prevalence of 0.84% blindness[11] which is comparatively lesser than that of India (1.34%)[15], has even low prevalence of uncorrected refractive error in children accounting 2.9%[16] than those reported in China (27%)[17], Chili (15.8%)[18] and Urban children(6.4%) in India[19]. However, reports from community based survey and schools screening conducted by different organizations in Nepal have shown the prevalence of uncorrected refractive error in children as high as 18.6%[20] in certain communities. Leon Garner reported prevalence of myopia to be 21.7% in the Tibetan Children who led an urban lifestyle[21]. Beside this, the unseen prevalence of blindness due to uncorrected refractive error in adults and presbyopia has significant impact on economic blindness and needs to be addressed immediately. Hence, basic eye examination and uncorrected refractive error correction should be given high importance while developing and implementing national plans for eye care services. Primary eye care and refraction services are the most important and crucial element in eye care services to decrease the prevalence of blindness as well as economic burden of it. This can be simply done by basic eye examinations so as to identify and refer blinding ocular diseases and provide refraction services at communal level. This services are best served by mid level eye care personnel who are trained to do so. The health education and disease identification at rural and remote communities even can be done by trained primary eye care workers. The referral network if build up networking all primary eye care centre to eye hospitals, the combat against blindness will run in an effective way and meet the national objectives of Vision 2020. 20 | P a g e

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The prime responsibility of basic eye examination and provision of refractive services should be given to mid level eye care personnel who are identified as Ophthalmic Assistants, Ophthalmic technicians/technologists, Refractionists, Opticians, Orthoptists and Ophthalmic nurses. Optometrists, who are identified as professional eye care personnel by Refractive Error Working Group[22] of World Health Organization, should play a contributory role regarding the refractive services and provision of affordable reasonable-quality spectacles to the community. The leadership of optometrists in the field of refractive error correction and primary eye care can ultimately meet the global initiative of reducing avoidable blindness by 2020. Despite mix of skills and diverse ophthalmic courses, the produced mid level eye personnel should be utilized properly in the community level providing adequate infrastructure for primary eye care and refraction services. Primary eye care centre should be developed in all districts and possibly develop as vision centers facilitating the logistics of providing affordable spectacles. This comprehensive approach will ultimately help reducing blindness and visual impairment in Nepal.

References:

Role of optometrist in pediatric eye care

Dr. Jyoti Baba Shrestha Pediatric Ophthalmologist

B-Optom Program Co-ordinator

In Nepal, Census Bureau (2006) reported that there are 12.5 million (40%) children under 18 years of age of which 3.6 million are below 5years. Vision and vision related disorders are the common disability and the most prevalent handicapping condition during childhood. A refractive error study from the Mechi Zone of Nepal conducted in 1997 showed 2.9% children had visual morbidity of which 56% was due to refractive error.1 21 | P a g e

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A study on ocular morbidity in schoolchildren has also reported refractive error as the commonest type of ocular morbidity (8.1%).2 Optometrists are independent primary health care providers who specialize in the examination, diagnosis, treatment and management of diseases and disorders of the visual system, the eye and associated structures. All optometrists are thoroughly trained, through their clinical education, training, experience, have the means to provide effective primary eye and vision services to children. They are uniquely qualified to deal with functional vision disorders and/or problems in visual processing which affect reading, and other aspects of learning, development and behavior. They also work with the visual rehabilitation of children with low vision; provide non-surgical solutions and surgical consultations. Pediatric Optometry Service offers a wide range of specialized eye and vision care, including: Complete optometric care to children 16 years of age and younger Management of problems of eye focusing, eye alignment, depth perception, accuracy of eye movements, and binocular (two-eyed) vision in patients of all ages Evaluation and treatment of visual information processing skills related to learning problems Vision therapy, a personalized program designed to train the eyes to work together Evaluation and non-surgical management of strabismus (turned eye) Contact lens service for all types of refractive error including special cases like aphakia and keratoconus. The optometrists are also responsible for educating parents or caregivers about any eye or vision disorders and vision care. Many parents and caregivers believe the screening performed by the child's pediatrician or other primary care physician or school nurse is sufficient to rule out all significant visual disorders. However, these screenings are limited and are not intended to replace a comprehensive eye examination. Early detection and preventive care can help avoid, or minimize, the consequences of disorders such as amblyopia and strabismus. The optometrist can also play an important role by educating parents/caregivers and children about eye safety, particularly regarding

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sports-related eye safety as sports and recreational activities also account for the eye injuries reported. Optometrists are the appropriate ophthalmic manpower to take the responsibility in pediatric eye care. Ophthalmologists and optometrists together make a complete eye care team for pediatric population. Divided we fall, united we stand, so lets work together hand in hand to reach the unreached. References: 1.Pokharel GP, Negrel AD, Munoz SR etal. Refractive error study in children: results from Mechi Zone, Nepal. Am J Ophthalmol 2000; 129:43644. 2. Nepal BP, Koirala S, Adhikari S, Sharma AK. Ocular morbidity in school children in Kathmandu. Br J Ophthalmol 2003;87:531-4

ARC More Than a Cosmetic Technology - Dr. Subodh Gnyawali 23 | P a g e

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Optometrist, Vision Care Centre A common problem with prescription of glasses and sunglasses is called back-glare. This is light that hits the back of the lenses and bounces into the eyes. The purpose of an anti-reflective (AR) coating is to reduce these reflections off the lenses. In bad cases, you can actually see the reflection of your own eye in the lens. AR is made of a very hard thin film that is layered on the lens. It is made of material that has an index of refraction that is somewhere between air and glass. This causes the intensity of the light reflected from the inner surface and the light reflected from the outer surface of the film to be nearly equal. When applied in a thickness of about a quarter of light's wavelengths, the two reflections from each side of the film basically cancel each other out through destructive interference, minimizing the glare you see. AR coatings are also applied to the front of prescription eyewear and some sunglasses to eliminate the "hot spot" glare that reflects off the lens. An anti-reflective coating can be beneficial when driving at night, working long with computers and improving your appearance, particularly when taking photographs while wearing your glasses. AR technology adds so much more value to your patient's visual comfort and eye health than simple cosmetic ego enhancement. Depending on the AR you choose, this one technology adds all or most of these desired benefit enhancements to a patient's eyeglasses. AR has the inbuilt property of scratch resistance. The superior clean-ability that comes with hydrophobic soil-resistant technology is usually not available as a separate benefit, but is included in almost all AR technologies. The Anti-Static property reduces dust collection on the eyeglass lenses, therefore diminishing the frequency of cleaning and the chance of scratching the lenses during cleaning. This benefit of enhanced visual acuity between lens cleanings is not available separately, but is included in superior AR technologies. The quality of protection the latest AR technology implies will differentiate these ARs from the negative memories of poor adhesion, poor cleanability, and general dissatisfaction with early iterations of AR technology. The benefit that is associated with the multi-layer technology of all ARs is glare reduction, especially apparent at night, which allows more of the diminished ambient light to enter the eye. This reduces double images and is especially helpful for the visual acuity of older patients. While AR increases light transmission on transition and polarized lenses, it also reduces reflections back into the eye from harsh and bright sunlight. An important benefit of AR on transition lenses is that it speeds transition significantly faster as your patient goes from one light-intensity to another. That is a benefit your patients will value.

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Infectious Keratitis a clinical distinction

Dr Meenu Chaudhary Lecturer Keratitis implies supparative non-viral and viral keratitis. Despite the availability of a wide range of newer antimicrobials and new diagnostic techniques, infective keratitis continues to pose a diagnostic and therapeutic challenge. Infectious keratitis is of two types suppurative and nonsuppurative. Nonsuppurative infectious keratitis can be viral, spirochaetal, parasitic or immune related stromal necrosis. The causative agents of infective keratitis are: 1. 2. 3. 4. Bacteria: Gram-positive cocci and Gram-negative bacilli Fungi: Filamentous fungi Viral: Herpes simplex virus Parasite: Acanthamoeba species

Clinical Diagnosis of Microbial and Viral keratitis. Why is the clinical diagnosis of infectious keratitis crucial? Even wellestablished laboratories can grow up to 60-70% of ocular pathogens from the material sent for culture. So, the management of rest of 30-40% of patients with corneal ulcer solely depends on clinical diagnosis. Infective keratitis developing after LASIK poses a problem to make clinical diagnosis due to the level of the lesion and steroid use. Clinicians should be aware of the commonly reported microbes from these patients (e.g., Nocardia, mycobacteriae and filamentous fungi). The clinical diagnosis of microbial keratitis often relies on a thorough history, especially history of infectious exposure, epidemiological trends and the morphological features of corneal inflammation. Ophthalmologists use clinical clues to recognize ocular surface infection. Some distinctive, though not pathognomonic, signs unique to the causative organism may help to differentiate bacterial, fungal and amoebicpathogens of the cornea. Bacterial keratitis

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All over the world, bacterial keratitis is more common than fungal keratitis, but this does not hold true for tropical countries. In our country, the following risk factors have been identified as leading cause to corneal ulcer: trauma, xerophthalmia, measles, malnutrition, diarrhea, ocular surface problem, eyelid abnormalities and rarely contact lenses. Trauma to the cornea accounts for 60-70% of cases developing corneal ulcer. The clinical picture may vary especially when the ulcers have been previously treated. However, a few classical clinical descriptions are useful. For example, Gram-positive organisms tend to produce discrete, small abscess-like lesions and Gram-negative bacteria are more likely to cause diffuse, rapidly spreading necrotic lesions. Watering, pain and vision loss are more severe in rapidly spreading bacterial ulcer caused by Pseudomonas and Streptococcus pneumoniae species. Indolent ulcers due to Moraxella and Staphylococcus spp. may be quiet and less symptomatic. Marked lid edema and conjunctival chemosis and purulent exudate are commonly associated with Gram-negative organisms, especially gonococcal infection. Hemorrhagic hypopyon is attributed to either pneumococcal or HSV keratitis. If there is purulent or mucopurulent discharge from lacrimal sac, the keratitis could be due to Pneumococcus in 90% of cases Gonococcal ulcer was common in infants but due to improved antenatal and postnatal care, we rarely see this ulcer nowadays. Among the causative organisms for infectious keratitis, Nocardia is uncommon. Trauma with organic matter or dry soil is found to be the major predisposing factor. Typically, the ulcer runs a slow and protracted course. The lesion appears as a cracked windshield or resembling a group of pinhead-size yellowish white infiltrates arranged in a wreath-like fashion which is considered as the classic clinical picture. The ulcer remains superficial and may have associated hypopyon. The ulcer does not respond to conventional treatment. Viral keratitis HSV Herpes simplex involves all the layers of cornea. HSV causes a spectrum of ocular diseases, but most prominent among them are epithelial and stromal keratitis. Recurrence in the same eye is the hallmark of this common viral infection involving the human cornea. Epithelial keratitis Symptoms include photophobia/blurred vision, irritation/pain and a thin watery discharge occasionally associated with cold sores around the lips and nose or genital sores. Corneal vesicles in the epithelium are one of 26 | P a g e

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the first manifestations of acute HSV infection, which manifest as a fine punctate keratitis or stellate whitish opaque plaques that coalesce into dendritic lesions over 24 hours. Eruptions of the corneal epithelium due to HSV are characteristically thin, branching dendritic ulcerations, wider, branching dendrogeographic ulcers or map-shaped geographic lesions. The edges of the ulcer become slightly raised due to the presence of edematous epithelial cells. Corneal sensation may be temporarily reduced or absent in 60% of affected patients. Stromal reaction is usually absent or mild and confined to the anterior layers. Most dendritic ulcers will heal spontaneously within 2 weeks. Trophic or metaherpetic ulceration appears as an ovoid lesion which runs a protracted course. The edges are rolled and gray in appearance and do not stain well with rose bengal. The base of the ulcer will stain with fluorescein or rose bengal. The defect may persist for weeks or months carrying with it a risk of melting and perforation. This entity should be thought of when we manage a case of nonhealing corneal ulcer. Sometimes, it is very difficult to differentiate from suppurative keratitis of nonviral origin. Presence of old scar or vascularization may help in arriving at a correct diagnosis. HZO Fifty to 72% of patients with periocular zoster will have ocular involvement. The frontal branch of the trigeminal nerve is by far the most frequently involved nerve. Involvement of the nasociliary branch can often herald ophthalmic involvement due to its innervation to the eye. The classic Hutchinson's sign (eruptions on the side of the tip of the nose) is evidence of nasociliary involvement and has 85% reliability that the eye will be involved. Herpes zoster begins with a prodrome of severe onesided headache, malaise, fever and chills, followed by erythema and papules in 2 or 3 days. Occasionally, zoster may develop without vesicles and rarely can affect both sides of the ophthalmic division. Previous attack of chickenpox may be present. When a young patient gets zoster, one should always rule out HIV infection or other immune-compromised diseases. Fungal keratitis This is more prevalent in tropical countries and frequently affects young rural men engaged in agriculture and other rural population. The incidence ranges from 35 to 50% in India. Keratomycoses most often picks up healthy cornea exposed due to minor abrasions. Chronic ocular surface problem, steroid use, immunocompromised host, diabetics and contact lens wearers may rarely get fungal ulcer. In Nepal aspergillus and fusarium species are frequently isolated as causative agents. Clinical features 27 | P a g e

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Classically, fungal ulcer has been described to commence insidiously and run an indolent course. General features include a thickened epithelium, linear infiltrates often associated with satellite lesions, the presence of an endothelial plaque and posterior corneal abscess, an immune ring infiltrate, a cheesy hypopyon (sometimes hemorrhagic) noted to often wax and wane, and fibrinoid aqueous reaction. The ulcers often appear dry, but most often it is not true. The ulcer base has a raised, wet, soft and creamy grayish-white or yellowish-white infiltrate without mucus or exudates. In case of pigmented fungi, the surface appears dry, tough and leathery. In the early stages, a dendritic pattern may be seen which is often misdiagnosed as HSV keratitis. Absence of lid edema, minimal conjunctival injection and feathery borders in a healthy adult from rural agrarian population with a recent injury to the cornea with organic matter should strongly favor a diagnosis of fungal ulcer, unless otherwise proved. Acanthamoeba keratitis Acanthamoeba keratitis is a painful, sight-threatening and difficult-to-treat corneal infection caused by the parasite acanthamoeba. Acanthamoebae are ubiquitous in nature. At least eight pathogenic acanthamoeba subtypes cause keratitis. The first case of keratitis in humans was identified in 1973 in an American farmer with ocular trauma. The incidence of acanthamoeba keratitis is about 1% among culturepositive infective keratitis in India. In Europe and the United States, the incidence among contact lens wearers is 1.65 to 2.01 per million contact lens wearers per year by epidemiologic estimation. In India, contact lens wearing is rarely associated with acanthamoeba keratitis. Clinical features Suspicion is paramount. It runs a chronic course and diagnosis is often made several weeks after the onset with a poor response to conventional treatment regimen for an infective keratitis. It is often misdiagnosed as HSV keratitis, fungal infection or topical anesthetic abuse. Even though pain out of proportion has been described as a prominent symptom by many, it is of the same severity as reported by patients having other types of keratitis. The disease is usually unilateral, but rarely may be bilateral in contact lens wearers. The corneal epithelium appears sick, edematous, loose and stroma may be hazy; and sometimes mimics an epithelial keratopathy. Radial perineuritis, one of the early clinical signs, is not a, common feature in noncontact lens wearers. Hypopyon is common. In well-established cases, the dense stromal ring infiltrate at mid-periphery of the cornea, sparing 28 | P a g e

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the pupillary area is considered as the diagnostic clinical sign of acanthamoeba keratitis. Associated scleral involvement near the limbus could be seen in inappropriately treated cases. Co-infection with bacteria and fungi is not uncommon and is reported as 2-3% in India. Investigative modalities Standard recommended guidelines for diagnosis of infectious keratitis consists of corneal scraping, tear samples and corneal biopsy for diagnosis and initiation of therapy .In bacterial, fungal and amoebic keratitis, microscopic examination of smears is essential for rapid diagnosis. Potassium hydroxide (KOH) wet mount, Gram's stain and Giemsa stain are widely used and are important for clinicians to start empirical therapy before microbial culture results are available. In cases of suspected viral keratitis, therapy can be initiated on clinical judgment alone. If a viral culture is needed, scrapings should directly be inoculated into the viral transport media. In vivo confocal microscopy is a useful adjunct to slit lamp bio-microscopy for supplementing diagnosis in most cases and establishing early diagnosis in many cases of non-responding fungal and amoebic keratitis. This is a non-invasive, high resolution technique which allows rapid detection of Acanthamoeba cysts and trophozoites and fungal hyphae in the cornea long before laboratory cultures give conclusive results. Other new modalities for detection of microbial keratitis include molecular diagnostic techniques like polymerase chain reaction, and genetic finger printing by pulsed field gel electrophoresis

Visual Rehabilitation for Children with Nystagmus

Jyoti Khadka Optometrist, PhD Student School of Optometry and Vision Sciences Cardiff University, UK

Nystagmus

is

an

eye

anomaly

manifested

by

involuntary

eye

movements, usually noted as "jerky" or "jumpy" eye movements. It often 29 | P a g e

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occurs in early childhood as a lone condition without any known cause (often called congenital nystagmus) or can be associated with wide range of eye disorders of childhood such as cataract, glaucoma, retinal defects, albinism, squint etc. Congenital nystagmus is usually mild and nonprogressive. The affected children are not normally aware of their spontaneous eye movements but vision can be impaired depending on the severity of the movements due to the lack of steady fixation which is usually required for good vision. Nystagmus is a relatively common clinical condition in children, affecting 1 in every 1000-6000 individuals. Several studies have shown that it is the commonest causes of visual impairment in children in the Western world. So, it is imperative that children with nystagmus should be taken seriously as they need timely eye check up and proper low vision assessment if required. This article is devoted to congenital nystagmus, exploring its effects on children and the avenue of visual rehabilitation. Effects of Nystagmus in children Congenital nystagmus is not curable but it is manageable. Children with nystagmus are affected in various ways as described below; Almost all children with nystagmus have some degree of reduced vision. Vision may vary during the day and is likely to be affected by emotional and physical factors such as stress, tiredness, nervousness or unfamiliar surroundings. Latent nystagmus is quite common; the nystagmus movements often increase when one of the eyes is covered, resulting in further reduction in vision. Near vision is usually better than distance vision. Depth perception is usually considerably reduced. Children with nystagmus may get tired more easily because of the extra effort involved in looking at things.

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Children with nystagmus may read slowly because of the extra time needed to scan. Children with nystagmus may turn their head and eyes in various positions to make the best use of their vision. Confidence may be reduced because of poor vision and maintaining eye contact may be difficult.
A child with nystagmus turning his

Visual Rehabilitation

Some children with nystagmus are mistakenly thought to have learning difficulties because the real problems caused by their poor vision are not addressed. The role of proper eye check ups, low vision assessment and the use of appropriate low vision aids (LVAs) are crucial. Often children prefer large print over LVAs, however, it is important that they are encouraged to use LVAs as there will be situations in life where large print is not available and LVAs may be the only option. LVAs are more useful when the print can't be enlarged and there isn't a CCTV e.g. when in a shop, at a friends house, science laboratory in school, reading comics and magazines etc. Some possible visual rehabilitation options that may be useful to improve visual function in children with nystagmus are discussed below If the reduced vision is associated with refractive error (long or short sight), it is likely that simple prescription for glasses will help lessen the effect and significantly improve visual function. Glasses, however, do not cure nystagmus. Plenty of stimulation in the early years does seem to help them make best use of the vision they have. Toys which encourage the child to follow a moving object, such as bright colored marbles or train sets, are helpful to develop hand-to-eye coordination Low power but large field magnifiers like bright field (dome) magnifiers, which allow longer working distance can be beneficial. The small size hand held magnifiers that fit in a pencil case or a pocket or on a string around the neck for 31 | P a g e

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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 Most children with nystagmus can see small print close to their eyes. Some may find visual aids like high power reading glasses (such as hyperocular +16.00) very useful for reading in bed at night or magazines/ comics at home. However, large print material should always be made available and all written matter should be clear, especially at school. Reading materials should be enlarged at high contrast. Binoculars are suitable for distance viewing like watching wildlife or sports. Some children with nystagmus seem to struggle to use a monocular which may be because nystagmus gets worse when using only one eye.

Electronic magnifiers like CCTV, laptops with magnifying software, portable CCTV are often better accepted by children than magnifiers.

Timed tests may create emotional stress that can cause the nystagmus to increase and the childs vision to

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temporarily decrease. Children also tend to read slowly, so they must be allowed extra time to study and when sitting for exams. Many children with nystagmus have a null point where the eye movement is reduced and the vision is improved. They will often turn their head to one side to make the best use of their vision. Teachers should allow children to use their preferred head position. It is often helpful if the children are allowed to sit to one side of a screen or the white board in the class room. Children should always be provided with their own books and worksheets as sharing materials may make it difficult for them see clearly, as the materials may be too far away or at the wrong angle for their best vision. Computers use can be tiring. Parents and teachers should help children to position screens to suit their needs and adjust brightness, character size, color combination. A large screen may be needed. A simple clear yellow sheet with a black line across it may be helpful in keeping ones place especially when looking away to the blackboard or to a computer screen. Depth perception is usually considerably reduced and as a result balance may be affected which may make it difficult to use stairs or cross uneven surfaces. Children should be given extra care while navigating. Children with navigation problem can benefit from orientation and mobility training. Some children with a null point dont scan the environment well, so may need extra supervision when crossing roads. Some children may be sensitive to bright light, so they should be allow using tinted glasses, peak caps for outdoor activities even in the school.

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Besides visual rehabilitation there are other therapies that can have benefit. These may include special types of spectacles i.e. applying prism to place eyes in null point positions or inducing more convergence, may reduce nystagmus slightly and improve the childs cosmetic appearance. Some researchers also have suggested that contact lens wear can establish better visual function and reduce the nystagmus more than glasses. Eye muscle surgery is sometimes employed in cases where a significant null point is found in an extreme position of gaze. However surgery cannot correct or cure nystagmus.

Nystagmus is neither painful nor does it lead to progressive loss of vision. Problems resulting from congenital nystagmus tend to improve until vision stabilizes around the age of five or six. Accurate information and support during the early years does make a big difference. Proper visual rehabilitation can reduce the effects of nystagmus to ensure that children have the same access to the same opportunities as fully sighted children. Parents and teachers should seek assessment from local low vision services where LVAs are freely available and if they dont work they can be easily swapped. Nowadays low vision practitioners should able to provide LVAs that look acceptable to children; which are small and look cool. The new portable CCTVs can even be envy of classmates. If required, specialist teachers or rehabilitation workers can provide training in the use LVAs in school. With the support of teachers trained in visual impairment, an

understanding school and the help of parents, most of the difficulties presented by nystagmus can be overcome. It is crucial that the teacher understands how to help a child with nystagmus and associated vision loss. The teacher must understand the need for the child to turn his eyes or head in a specific manner. Allowing the child to sit at the front of the classroom and the preferred location can help to maximize childs visual potential. The parents and the teachers should particularly conscious 34 | P a g e

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about their childrens emotional state, if their children are teased. If such a thing happens, lessons for everyone with magnifiers, binoculars and shared information on nystagmus can help.

NEW SILICONE HYDROGEL LENS FOR CONTACT LENS-RELATED DRYNESS

(AN INSIGHT TO SILICONE HYDROGEL LENS) -Asik Pradhan Optometrist Doha, Qatar It is a well known fact for all the contact lens practitioners that contact lens causes dry eyes. As the primary reason for lens discontinuation, dryness is always a concern, affecting approximately half of all soft lens wearers. The options available to the wearer to reduce it are limited: either to use rewetting drops, or simply to remove the lenses. Continued lens removal by the wearer beyond the point it becomes uncomfortable, coupled with a shorter than desired comfortable wearing time, can lead to the wearer lapsing in the long-term. Dryness can be exacerbated for certain wearers depending on their lifestyle, leisure/work environment and other factors including: Screen usage, which has predominantly been cited as using PCs at work, but can also include: o Television viewing o Increasing use of PCs or home 35 | P a g e

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o Personal digital assistants (PDAs) o Mobile phones Smoky/polluted environments, which both dry and contaminate the eye Air conditional/central heating Frequent flying Medication causing ocular dryness, for example, anti-histamines, beta-blocker and birth control pills Some wearers would also like to use contact lenses in situations where spectacles are unsuitable, for example, for example sports, but have been unable to do so to date due to a tendency to suffer dryness symptoms that have made wearing lenses too uncomfortable. These wearers will benefit from a lens with greater comfort. Dryness, and more generally lens discomfort, cannot be substantially improved by changing a single material property. Comfort needs to be tackled by changing various properties of the lens, while at the same time maintaining a balance between their material advantages and disadvantages. The recently upgraded four material properties that can influence contact lens wear are discussed below: Oxygen Performance A new silicone hydrogel material, senofilcon A has increased silicone content. This material has a higher Dk/t (oxygen transmissibility) of 147 standard units, significantly greater than hydrogel lenses. This high oxygen transmissibility exceeds the criteria for maintenance of oedemafree and acidosis free daily wear and extended wear. However, oxygen flux is increasingly being cited by researchers as a more clinically relevant measure for oxygen performance, especially in silicone hydrogel era. Oxygen flux calculates the volume of oxygen that reaches a unit area of the corneal surface in unit time, can be usefully quoted in terms of percentage oxygen available to the cornea compared to no lens wear. This new material with hydraclear technology allows 98% of the oxygen through the lens compared to wearing no lens at all for daily wear, and 96% for extended wear. Wettability Surface wettability is important for stable vision, comfort and biocompatibility. Typically with conventional hydorgel lenses and first generation silicone hydorgels, this has been achieved by a coating (of vinyl pyrrolidone) or surface treatment on the lens to render the surface more wettable. Rather than using a surface coating the Hydraclear technology used for this lens blends the moisture rich wetting agent (vinyl pyrrolidone) with high performance base materials to create a more wettable, ultra smooth contact lens. The wetting agent is a long chain high molecular weight molecule that acts as a hydrophilic humectant-that is absorbs moisture and promotes the retention of the moisture it retains. 36 | P a g e

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The dynamic contact angle for this material is less than 900 indicating that less resistance is provided by the material, hence increase the wettability. Lubricity Lubricity is the property of a wetted material to resist friction. In respect of contact lenses, it represents the level of friction sustained by the eyelid traveling across the lens surface. It is measured by moving a known load at a fixed speed across the wetted surface of the lens material. The coefficient of friction for this material is the lowest ever proven among all hydrogel and silicone hydrogel lenses. As a result it gives the lens a smooth feel that allows the eyelid to travel over the lens with reduced irritation. Typically the eye blinks about 8,000 times per day, highlighting the importance of reducing frictional resistance. Modulus Elastic modulus relates to the ability of the material to drape or contour to the eye surface. As this property indicates the stiffness of the material it also directly relates to the mechanical resistance to the eyelid and cornea. High mechanical resistance to the eyelid and cornea, which can result in poorer contouring, sometimes exhibited by edge fluting, can cause complications such as superior epithelial arcuate lesions (SEALs), contact lens papillary conjunctivitis (CLPC), and mucin ball production in post-lens tear film. It is, therefore, important to balance the lens materials modulus so that it is neither too stiff nor too flexible allowing the lens to deform. A lens that is too rigid can result in excessive movement in the eye and poor centration; a lens that is too flexible can cause handling problems. This lens material has low modulus as hydrogel lens but significantly lower than other silicone hydrogels, hence exhibits good balance of flexibility. UV blocking UV inhibitors (benzotriazole) in contact lenses have become popular as a method of reducing risk to patients of developing chronic UV induced pathology, for e.g.; carcinoma, pinguecula, keratitis and cataract. Pterygium is one particular condition highlighted recently, and is thought to be caused by UV radiation entering the eye obliquely and then refracted by the cornea. UV protection is recommended for all patients and especially those who participate in leisure or work activities that expose them to high levels of UV. This silicone hydrogel material with its UV inhibitor content is able to achieve Class I UV-blocking. It blocks 96% of UV A rays and 100% of UV B rays. Summary For the increasing demand of population requiring comfort and dryness resistance under challenging conditions silicone hydrogel materials are 37 | P a g e

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proving to be a boon for them. With the combination of wetting agent within the material of the lens, it attesting to increase comfortable wearing time for existing wearers, also allows exceptional comfort to demanding wearers, exposed to drying environments or tasks. Table 1. Summary of lens properties:
Lens material Senofilcon A Wetting agent Vinyl pyrrolidone Water content 38% FDA Group Group 1( low water, non-ionic) Oxygen percentage available 96% available (closed eye) at cornea 98% available (open eye) Dk+ 10310-11 standard units Dk/t 14710-9 standard units Visibility tint Yes UV- blocking Class 1: 96% UVA, 100% UVB Recommended wear 2-week daily wear, 1-week extended schedule wear

References 1. Dr.Kathy Osborn and Jane Veys, Acuvue oasys research, Eye Zone, Arab Optical Magazine, Issue 18, March-April, 2008. 42-43. 2. Chalmers R, Begley C. use your ears (not your eyes) to identify CLrelated dryness. OPTICIAN, 2005;229,6000. 3. Brennan NA. Corneal oxygenation during contact lens wear: comparison of diffusion and EOP-based flux models. Clinical and experimental optometry, 2005 Mar,;88(2):103-8 4. Naim J, Jiang T. Measurement of the friction and lubricity properties of contact lenses: 1995. 5. Marc B Taub OD. Ocular effects of VU radiation. Optometry Today, June 18, 2004. 6. Troy E. Fannin, Theodore Grosvenor; Effects of radiation on the eye, Absorptive Lenses and Lens Coatings, Clinical optics, second edition.

Pediatric Strabismus: Evaluation and Management

Dr. Sanjeev Bhattarai M.Optom.,O.D.
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Pediatric age includes a child from birth to fifteen(15) years of age.It also encompasses the critical period of child(till 8 years) within which all the binocular visual development should be completed. Any neurosensory and motor imbalances within this period can lead to visual disaster including amblyopia, strabismus, suppression and eventually may be blindness. Briefly the visual milestones in pediatric group are as follows: Birth-1 week=Fixation present, follows horizontally moving targets .OKN visual acuity of 6/120 4 weeks-8 weeks=Fixation will be developed, follows vertically moving objects, fusion starts to develop. 4months=Accommodation developed and foveal differentiation completed. 5 months=Blink response to visual threat. 6 months=Visual acuity of 6/6 by VEP, stereopsis developed, fusional convergence well developed 18 months=Visual acuity of 6/6 by acuity cards. 3 years=Visual acuity o 6/6 by E chart, HOTV chart 5-7 years=Stereopsis well developed to adult level. Strabismus: It is a vision condition in which a person can not align both eyes simultaneously under normal conditions. One or both of the eyes may turn in, out, up or down. An eye turn may be constant or intermittent, but it always requires appropriate evaluation and treatment. It is estimated that up to 5% of all children have some type or degree of strabismus. Children with strabismus may initially have double vision due to misalignment o the two eyes. Synonyms for strabismus are like Squint, Crossed eye, Wall eye, Cock eye etc. Symptoms: Eyes appear crossed, uncoordinated eye movements, double vision, vision in only one eye, loss of depth perception etc. Causes: Strabismus may have the onset from congenital, acquired or secondary to another pathological process. It is mainly due to lack of coordination between the eyes. In most cases of strabismus in children, the cause is unknown. A sensory obstacle to fusion can trigger squint. It may be ptosis, corneal/ lenticular/ vitreous opacity, maculopathy, retinoblastoma, optic neuropathy etc. Lesions in first few months of life gives rise to exo or eso deviation. Lesions from 4 months to 4 years usually give rise to esodeviation due to developing convergence tonus. After 4 years, exodeviation develops as convergence becomes balances with divergence.

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Other causes that can give rise to exotropia/ esotropia are like refractive errors, extra ocular muscle anomalies, weak fusional reserves, low or high AC/A ratio, wrong and ill fitted spectacles, aniseikonia, poor health, fatigue and head injury, anatomical faulty muscle insertion and action, neurological and pathological problems. Some disorders associated with strabismus in children include the following: Retinopathy of prematurity (ROP), retinoblastoma, traumatic brain injury, hemiangioma near the eye, Alport syndrome, Noonan syndrome, Mobius syndrome, trisomy 18 etc. Pseudo-strabismus: Condition in which visual axes of the two eyes are in fact parallel in all positions of gaze and there exist a normal bi-foveal vision but eyes appear to have a squint. Causes for pseudo-esotropia are small inter-pupillary distance (IPD), broad nasal bridge, prominent epicanthal fold, enophthalmos, etc. Causes for pseudo-exotropia are wide IPD, narrow nasal bridge and narrow lateral canthi, exophthalmos, facial asymmetry etc.

Evaluation: Evaluation part consists of following steps

History: Regarding time of onset, trauma, symptoms and head posture should be taken. It also includes birth history, family history and previous treatment underwent. Visual acuity, refraction, retinal examination, neurological examination, ocular movement, Hess screen etc. Qualitative diagnosis of strabismus in children include cover test, cover uncover test, Bruckner test etc. In Bruckner test direct ophthalmoscope is used for observing the red reflex from both eyes simultaneously so that it helps to detect the deviating eye, which shows the brighter reflex. Quantitative diagnosis includes Hirschbergs test, Krimsky test, alternate prism cover test, Maddox rod test, Maddox double rod test etc. Suppression test includes Worths four dot test,4 prism diopter base out test, red glass test, synaptophore test etc. Eccentric fixation test in children includes corneal light reflex test (angle kappa), visuscope projection test etc. Stereopsis test in children include Lang two pencil test, Random-dot stereo test, TNO random dot test, Titmus stereo test etc.

Treatment and Management

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The primary therapeutic goal is comfortable, single, clear; normal binocular vision at all distances and directions of gaze. Early treatment in infancy can reduce the chance of developing amblyopia and depth perception problems. Initially proper refractive correction should be made. Amblyopia if associated can be treated with use of of an eye patch on the dominant eye with active vision therapy. Optical treatment: For any accommodative esotropia, full cycloplegic correction without making any tonus allowance for the cycloplegic used should be given. An under correction of hypermetropia is recommended to reduce the degree of consecutive exotropia. A slight overcorrection of myopia helps in controlling intermittent exotropia. Bifocal glasses are useful in controlling deviation of patients having non refractive accommodative esotropia. Prism therapy: For vertical deviation=Fresnel press-on prisms in patients with small(less than 12 PD) comitant vertical deviation. For horizontal deviation=for relief of diplopia in visually nature patients. Pharmacologic treatments Miotics: In cases of non refractive type of accommodative esotropia, for e.g. DFP 0.1% and Echothiopate 0.03% solution. Similarly, in cases of residual esotropia and consecutive esotropia. Atropine: For therapy of accommodative esotropia. Botulinum toxin=It blocks release of acetylcholine and paralyze the muscles for several weeks. It is use in the short term treatment o infantile esotropia and paralytic strabismus. Orthoptic treatment: For convergence insufficiency: Pencil push up test, physiological diplopia exercises along with base out prisms and on synaptophore. For overcoming suppression: Diplopia exercises, macular massage on synaptophore and occlusion therapy should be performed. Surgical treatment of squint: It is carried out to correct squint cosmetically as well as functionally. Patients with marked asthenopic

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symptoms and abnormal head-posture with squint should be referred for surgery. Paralytic squint: In such deviating eye, treatment should be initiated once the condition is stable and that non-spontaneous improvement is likely to occur. A hastily surgical treatment may result in over or undercorrection of deviation in some cases. In cases of diplopia, prisms o minimal strength or alternate patching of eyes should be carried out. However in most cases if the condition remains static for a period of 3-6 months, the surgical treatment may be considered. Conclusion: Pediatric strabismus if not treated and managed in time, can lead to a permanent weakening of vision. So it requires a prompt medical evaluation. If child complains of double vision, has difficulty in seeing, appears to be crossed eye, he/she requires a proper optometric/Ophthalmological evaluation in order to abstain from the amblyopia, suppression and other vision threatening situations. References: Fundamentals of Ocular motility-Von Noorden Fundamentals of Binocular vision-Robert D Dale Management of Strabismus-Kyeth Laly Strabismus simplified-Pradeep Sharma www.google.com pediatric strabismus

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Glaucoma Diagnostic Tools: HRT and GDx

Mahesh R Joshi, Optometrist Om Hospital and Research Centre Historically Open Angle Glaucoma is considered as a disorder of the intra ocular pressure and subsequent optic neuropathy. Diagnosis of this disorder and when to begin the intervention has always been a subject of controversy over the years. Most of the practitioners treat the disorder on the basis of Intra-Ocular Pressure (IOP), Optic nerve head (ONH) changes and Visual fields. However these factors could vary with individual and provide less confirmatory diagnosis. The major limitation of IOP is that damage threshold varies with the individual. Majority of ocular hypertensive do not have glaucoma and will not develop glaucoma1 whereas other with IOP in the normal range might develop glaucoma (Normal Tension Glaucoma) 2. Other limitations are the diurnal fluctuation which might conceal high IOP spikes3 and effect of the corneal thickness4. Similarly ONH evaluation is a subjective method and might prove inadequate to differentiate the glaucomatous form physiologic cupping and also the progression of the disease might be difficult to detect. Visual field evaluation is again a subjective form of assessment and is frequently found to have high variabliity 5 and hence can improve with practice moreover there is a strong evidence suggesting that by the time there is visual field defect, the disease is already in a moderate to advanced stage6-12. Owing to these limitations and drawbacks, the emphasis has shifted to the assessment of the Retinal Nerve Fiber Layer (RNFL) for early detection and monitoring change over the time. It has been proven that the RNFL changes precede the visual field loss8-12 and optic disc changes13, 14. Various instruments based on different principles have been introduced in the recent times to facilitate the diagnosis by detecting early changes of the optic nerve head and more recently that of the RNFL. 43 | P a g e

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HRT: Heidelberg Retinal Tomogram HRT introduced in 1999, is based on a con-focal Scanning laser technology which provide three dimensional images of optic nerve head and very detailed quantitative data. HRT is a completely birefringent-free technology, unaffected by corneal artifacts hence provides reliable measurements. In this examination, three image series are taken automatically in seconds. These image series can have up to 192 individual optical sections which are combined into a mean allowing a creation of three-dimensional topography. Each three dimensional topography is derived from up to 28 million spatial data points to give exact measurements of retinal surface height and quantifies the structure of ONH. HRT scans as many as 64 images of optic nerve head in 2 seconds. The number of images depends on the depth of the cup; especially deep cup will yield up to 64 images to a depth of 4mm. HRT is said to detect initial ONH structural damage and accurately monitor the changes that precede the visual field loss. HRT hence focuses on the structural changes of optic nerve head such as cup and disc area, volume, neuro-retinal rim and other parameters of the ONH. Then comparing the patients individual data with the normative database and coming up with any abnormalities in these factors to determine the disorder and its progression. GDxVCCNerve Compensation Fiber Analysis with Variable Corneal

GDx is based on the principle of scanning laser polarimetry and provides comprehensive information of the damage to the retinal nerve fiber layer. Scanning laser polarimetry utilizes polarized light to scan the retinal nerve fiber layer. The polarized light is made up of two orthogonal components when this passes through the RNFL (a birefringent medium), one component is changed. This change called retardation is directly proportional to RNFL thickness. The scan captures an image with a field 400 horizontally by 200 vertically and includes both peri-papillary and macular region. Total scan time is 0.8 seconds. Apart from RNFL, anterior segment structures such as cornea and lens also are birefringent media and hence affect the final measurement of the RNFL thickness. GDx VCC compensates for this factor by individually calculating the birefringence contributed by these structures for each measurement in its corneal measurement hence this is called Variable corneal compensation (VCC). Earlier GDx such as GDx NFA and GDx 44 | P a g e

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Access compensated for the anterior segment birefringence with fixed age related values from cornea and lens derived from survey of large population and not from the individual being examined. Hence the GDx VCC is more accurate in determining the RNFL thickness then its predecessors. GDx generates two images: a reflectance and a retardation image. The reflectance image is generated from the light reflected from retina and is displayed as fundus image and the retardation image is the map of retardation values which is converted into a RNFL thickness. There is evidence that the RNFL measurements with GDx VCC correspond closely with the known RNFL anatomy.15,16 Thickness of the RNFL obtained from the measurement is compared with the age, ethnicity and gender matched data stored in the instrument and provides Thickness map and Deviation map with color coded probability of being within normal and abnormal range. In addition to these map, the average thickness of RNFL in TSNIT region is also provided along with unique Nerve fiber Indicator which has a high specificity to detect Glaucoma.

Figure: GDx report: The correlation between the Deviation Map (bottom), visual fields (top right), and the Thickness Map (top left) is shown for a normal, pre-perimetric, moderate, and advanced glaucoma eye. The red 45 | P a g e

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and yellow hues in the thickness map (Top) represent the normal finding with thick nerve fiber layer. While in the Deviation Map (Bottom) the red and yellow hues represents the area with thinner nerve fiber layer corresponding to the visual field defects. Summary Both HRT and GDx have been demonstrated to be useful and essential tool for detection and progression of Glaucoma. While HRT focuses more on the changes of the ONH and its various parameters for this purpose, GDx is more concerned with the RNFL thickness. As the focus has shifted towards the early detection of the disease and since the RNFL thickness provides the first indication of the glaucoma, GDx with its emphasis on the early detection of the RNFL changes probably has better accuracy in determining early glaucoma and its subsequent progression. However HRT provides us with better understanding of subtle ONH changes and better picture of the ONH. Hence correlating both these instruments with traditional indicator of glaucoma such as IOP and Visual field change will probably be the best way forward in detection and treatment of the disorder. REFRENCES 1. Kass MA, Heuer DK et al. The ocular hypertensive treatment study. A randomized trial determines that topical ocular hypotensive medication delays or prevents the onset of primary open-angle glaucoma. Arch Ophthalmol. 120: 701-713, 2002. 2. Collaborative Normal Tension Glaucoma Study Group. Natural history of normal tension glaucoma. Ophthalmology 108: 247-253, 2001. 3. Liu JHK, Zhang X, Kripke DF, Weinreb RN. Twenty-four hour intraocular pressure pattern associated with early glaucomatous changes. Invest Ophthalmol Vis Sci. 44: 1586-1590, 2003. 4. Doughty MJ, Zaman ML. Human corneal thickness and its impact on intraocular pressure measures: a review and meta-analysis approach. Surv of Ophthalmol. 44: 367, 2000. 5. Keltner JL, Johnson CA, et al. Confirmation of visual field abnormalities in the ocular hypertension treatment study. Arch Ophthalmol. 118: 1187-1194, 2000. 6. Quigley HA, Addicks EM, Green WR. Optic nerve damage in human glaucoma. III. Quantitative correlation of nerve fiber loss and visual field defect in glaucoma, ischemic optic neuropathy, papilledema, and toxic neuropathy. Arch Ophthalmol. 100: 135-146, 1982. 7. Quigley HA, Dunkelberger BS, Green WR. Retinal ganglion cell atrophy correlated with automated perimetry in human eyes with glaucoma. AM J Ophthalmol. 1989; 107: 453-464. 46 | P a g e

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8. Sommer A, Katz J, Quigley HA, et al. Clinically detectable nerve fiber atrophy precedes the onset of glaucomatous field loss. Arch Ophthalmol. 1991; 109: 77-83. 9. Sommer A, Miller NR, Pollack I, et al. The nerve fiber layer in the diagnosis of glaucoma. Arch Ophthalmol.1977; 95: 2149-56. 10. Tuulonen A, Lehtola J, Airaksinen PJ. Nerve fiber layer defects with normal visual fields. Do normal optic disc and normal visual field indicate absence of glaucomatous abnormality? Ophthalmology 1993; 100: 587-598. 11. Airaksinen PJ, Mustonen E, Alanko HI. Optic disc hemorrhages precede retinal nerve fiber layer defects in ocular hypertension. Acta Ophthalmol. 59: 627-41, 1981. 12. Caprioli J, Prum B, Zeyen T. Comparison of methods to evaluate the optic nerve head and nerve fiber layer for glaucomatous damage. Am J Ophthalmol. 121: 659-67, 1996. 13. Quigley HA, Katz J, Derick RJ, Gilbert D, Sommer A. An evaluation of optic disc and nerve fiber layer examinations in monitoring progression of early glaucoma damage. Ophthalmology 99: 19-28, 1992. 14. Airaksinen PJ, Alanko HI. Effect of retinal nerve fiber loss on the optic nerve head configuration in early glaucoma. Graefes Arch Clin Exp Ophthalmol 220: 193-196, 1983. 15. Weinreb RN, Dreher AW, Coleman A, Quigley HA, Shaw B, Reiter K. Histopathologic validation of Fourier-ellipsometry measurements of retinal nerve fiber layer thickness. Arch Ophthalmol. 108: 557-560, 1990. 16. Morgan JE, Waldock A, Jeffery G, Cowey A. Retinal nerve fiber layer polarimetry: histological and clinical comparison. Br J Ophthalmol. 82: 684-690, 1998.

Nepalese Optometrists: What they want to say?

Dinesh Kaphle , Optometrist Malawai

Background

To define Optometry and Optometrist in Nepal is not a new thing. Every time whoever writes about Optometry/Optometrist, the author seems to be unsatisfied without quoting the definition of Optometry/Optometrist. Short history of Optometry (here in Nepal) may be the reason behind this need of repeated reminders. World Council of Optometry (WCO) defines Optometry as a healthcare profession that is autonomous based on professional education and regulated (licensed/registered). Optometrists are primary healthcare practitioners of Eye and Visual system, who provide comprehensive Vision care including Refraction and Dispensing of lenses, Detection/ Diagnosis and Management of Eye Diseases and 47 | P a g e

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Rehabilitation of persons with Vision Impairment This definition is not necessary to explain again. In Nepal Optometry was started in 1998 A.D. to combat the goal of Vision 2020: The Right to Sight, under the affiliation from Tribhuvan University, Institute of Medicine. The initiation of the program was very enthusiastic. But the saddest part is nobody takes care of it. Nobody worried about the future of optometrists. Neither University nor the Ministry of Health took the issue as serious. Nepal Netra Jyoti Sanga (NNJS), which covers the majority of the eye services in Nepal, could not make the satisfactory space for optometrist as well. The interesting and serious matter is; why Optometrists are not getting favorable opportunity? Are the Optometrists not needed for the country? Is not there any role of Optometrists for the global mission of Vision 2020? If Optometrists can contribute to reduce the blindness of Nepal why is the concerned authority making delay for the Optometrists settlement within the country? Is optometry only the ladder for some individual to lift their career in eye care?

Are the Optometrists Not Qualified?

This is good topic of discussion. To blame as non qualified there must be some criteria and authentic body. If it is so, are all the products qualified? But this is not the big issue. These minor things can be sorted out soon if one is really interested. Everyone involved in the Eye care knows the capability of Nepalese Optometrists. Four year academic degree course is not an easy job to be achieved. Sufficient Clinical Exposure, Self Directed Learning (SDL), Seminars & Presentations and Field Program are some of the strengthening parts of the course. Nepalese optometrists are going to do neither LASIK surgery nor they are going to manage the Complicated Cataract and Retinal Detachment Surgery. There are so many problems in eye which can not be managed properly without the coordination with Optometrists. Orthoptic & Vision therapy, Contact Lenses and Low Vision Services are some of the fields which Optometrists can provide better than anyone. It is not the matter of competition. Optometrists do not pull the business of any others. Not a single profession is an alternative to another. Nepalese are in need of all eye professionals; Surgeons, Ophthalmic Assistants and even Optometrists. The number of Eye Health Professionals is still very far from the required one within the country.

What is the Impact?

It is appeared that optometrists are the only one who suffered a lot from this problem. It is not untrue in some extent. But this is not the problem of individual optometrist. This should be considered as one 48 | P a g e

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of the big issues of the country. Who is thinking about the countrys investment for Optometrists for four year degree? If we think for long term, individual is not losing more. Country is losing a lot because of lack of proper Policy and Planning for Optometrists. Almost half of the Optometry products are out of the country. Nepalese Optometrists are enrolled in reputed university of UK and Australia. They are doing better in Middle East, South Asia and even in Africa.

What can be done?

Everyone has his/her own identity in the world. Respect has to be given depending upon their capability. Now the issue is if it has been realized that Optometrists are needed for the country why it is being delayed for their settlement. Now people believe in Works rather in Workshops, Seminars, Reports and only the Speeches. Integration of all eye professionals has become mandatory now. Nobody prefers to work outside the country. Every body enjoys serving their own community. It is good to respect the feelings of every profession in time. Innocent Nepalese can not resist the unfair justice for longer.

Low vision management of retinitis proliferans-a case report Case report

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Nabin Raj Joshi B. Optom 8th Batch Retinitis proliferans refers to any Neovascularization of the retina extending into the vitreous body (Definition courtesy: The American Heritage Medical Dictionary). A 17 year old male presented to the low vision clinic with history of decreased vision in both eyes since childhood. He was accompanied by his aunt. He had a normal gait and was well adapted to the decreased vision suggested by his appearance and by the way he maintained his hygiene. He was the only person with visual impairment in the family and his elder sister was well. He had no family history of any systemic and ocular diseases and impairment. He was in the tenth standard. He had no history of glasses and was using a stand magnifier given from another low vision clinic. Optical aids for distance were not given as they were unavailable (Reference from patients documents). He had difficulty reading small prints in newspapers and school books. He couldnt write in a straight line and could sign documents. He had problems in distance viewing with inability to see in the chalkboard and difficulty in recognizing faces. He couldnt see the vehicles number plates and their color. He needed bright lighting conditions and preferred fluorescent lighting. He had slight mobility problems with difficulty at night and in unfamiliar places, but didnt bump into object and had no history of falls. He gave history of his preference of left eye. He had no complaints of delayed dark adaptation or poor color perception. He had no complaints in carrying out his daily living activities. According to the history, chief visual complaints were summarized as 1. Blurring of vision for near like newspaper or text books. 2. Difficulty in seeing chalkboard. 3. Difficulty in recognizing faces. Clinical examinationDistance uncorrected visual acuity OD 1.42 Log MAR, Os 1.12 Log MAR Near VA OU 1.6 M at 14 cms Refraction Objective finding OD) -1.00/-0.75 @ 045 OS) -1.00/-1.00 @ 180 Subjectively showed no acceptance and VA remained the same. Pupil was round, regular and reacting. Color vision assessment Could name colors up close but showed Decreased or no sensitivity to clinical testing. (Could see the demonstration plate but nothing more with Ishihara test plate, 38-plate edition.) 50 | P a g e

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Binocularity He had full ocular mobility with cover test showing Exotropia with R/L, almost 15 degrees with Hirschberg testing. Visual field assessment OD) Overall blur with Amslers grid and showed intact 16 degrees of field with a 1cm target with Bernells perimeter. OS) Central field intact with Amslers grid. Grossly 20 degrees all around with a Bernells disc perimeter. Trial of near vision devices 1. Spectacle magnifier (12 Diopter) 2. Stand magnifier (Previous prescription) Patients preference Spectacle magnifier with vision achieved to 0.60 M @ 8 cm. Reading and writing skills both were good. Trial of telescope Telescopes tried were 4x, 6x, and 8x Patient preferred 8 x telescope with visual acuity of 0.30 logMAR. Visual skills were good. Rehabilitation plan for the patient. 1. Supramount half eye framed spectacle magnifier (12 Diopters) 2. Reading stand 3. Telescope (6x) 4. Anti-glare screen in the computer 5. Certificate of low vision given 6. Letter to the school was given with descriptions of the arrangement of his seat and other associated information. Patient was given instructions about the use of the devices and was provided individual training on the handling of the telescope. Patient then was counseled and advised to follow up 1 yearly to the low vision and the retina clinic.

Discussions There are similar cases of low vision patients with similar complaints. The education system still lags behind their needs of improvement. The patients are still not aware of special privileges given to the low vision patients during exams and in their academics. The information about low vision and the advantages have to propagate to various corners of this

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country. More technology and policy has to come into Nepal to give people better opportunities to see and lead a qualitative life.

LITTLE

OPTOMETRISTS: BIG STEPS

Rajendra Gyawali B. Optom, 8th Batch Introduction Screening is the process by which unrecognized disease or defects are identified by tests that can be applied rapidly on a large scale. Screening tests sort out apparently healthy people from those who may have a disease. Screening is not usually diagnostic and it requires appropriate investigative follow up and treatment.1 It is a public health intervention measure which has to fulfill certain criteria but which may not always be possible in practice.2 According to Wilson and Jungner (1968), the disease should be one that would prove serious if not diagnosed early such as phenylketunaria and amblyopia in children. The cost of screening program must be balanced against the number of cases detected and the consequences of not screening. The screening test itself must be cheap, easy to apply, acceptable to the public reliable and valid.2 Launched on October, 2007, Little Optometrists is a part of eye screening and eye health education program of NOSS. This is training cum screening program intended to produce trained school students who can test vision and identify obvious abnormalities of eye and can refer to the eye care centre. Refreshment training and evaluation for their efficiency is done periodically. Secondary level students are trained in the presence to their school teacher to guide them. Necessary equipments and instruments were provided to them by NOSS. The screening and the follow up part is conducted by optometry students under the guidance of optometrists at the school itself. The screening is based on the Indiana school vision screening guidelines and modified clinical technique. The program is also intended to obtain the data about the magnitude of vision and eye related problems in school children. Little optometrists are involved in various awareness programs in schools and their society through Vision Club, under direct supervision of NOSS. Background The prevalence of blindness among children in different regions varies from 0.2/1000 children to over 1.5/1000 children with global figure estimated at 0.7/1000 children. This means that there are and estimated 1.4 million blind children worldwide .3 Many of the causes of childhood blindness are avoidable being either preventable or curable. Early detection is crucial and there is a greater urgency for the managing the 52 | P a g e

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problem, as delays in treatment can lead to amblyopia and other permanent visual impairment. It should be noted that these problems can be detected easily by simple screening programs targeted at school children.4 Vision screening is not diagnostic, but is a practical approach to identifying children needing professional eye services. It is an efficient, economical, and efficacious manner of detecting possible vision problems in the pre-school and school age populations. The purpose of the vision screening test is to separate those children who probably have no vision problems from those who should be examined by an eye doctor for potential problems and possible treatment. 10The early detection and treatment of vision disorders gives children a better opportunity to develop educationally, socially, emotionally and physically11 In addition to detecting vision problems, vision screening programs are valuable in raising the awareness of parents, teachers and the community to the importance of eye care. Another screening benefit is the identification of children who may need special education services because of a visual impairment. In developing countries like Nepal, the total population of trained eye care professionals (ophthalmologists, optometrists etc.) is very less to combat with nations blindness problems. So this manpower is still not in the stage to be directly and solely involved in the screening programs as mentioned above. Nepal Optometry Students Society (NOSS), since last few years, is working to fulfill this gap. Various eye screening programs for school children and general public, eye health education and awareness programs, exhibition are few of the endeavors taken by NOSS to fight against blindness in Nepal. Objectives To produce trained school students (little optometrists) who can test vision and detect obvious ocular abnormalities To conduct school eye screening programs with the help of little optometrists To provide optical and medical management to the students who need it, whenever possible To establish Vision club in each school which will be involved in vision screening and awareness programs To obtain the data on the magnitude of ocular and vision related problems in the school children To refer the students to eye care centre if detail examination is required To create public awareness about eye health by little optometrists

Methods and methodologies

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The little Optometrists program is divided in two major parts, training and screening. Training It involves one-day basic training in vision test and detection of ocular abnormalities. The students are given training on visual acuity taking procedures. The 6m Snellens chart is used which has literate side and illiterate (tumbling E) side. A class presentation and a practical session are conducted. The information about the lightening condition is also provided. They are trained to refer the student to eye hospital if any abnormality in vision is found. Students are given basic training on the detection of some of obvious abnormalities of eye o Squint (manifest deviation of eyes) o Red and painful eyes o Corneal opacities (Whitish opacities in black part of eyes ) o Ptosis (drooping of eye lids), misdirected lashes Students are trained about the first aid procedures regarding ocular injuries. The basic idea about ocular structures, refractive errors and the current scenarios of blindness in Nepal and world is also given. Screening Screening is done at the respective school. The trained little optometrists initially conduct a basic screening at their school through Vision Club. They take vision with Snellens chart and screen for any abnormality in eye and vision. The final screening is conducted by optometry students under the guidance of optometry instructor. The visual acuity, binocular examination, anterior segment evaluation, posterior segment evaluation is done for all the students. The dry Retinoscopy is done to the students who have subnormal visual acuity. The students who require further evaluation such as dilated fundus evaluation, cycloplegic refraction are referred to the eye hospital. The binocular examination includes Hirschberg test, cover test, convergence and ocular motility test. The posterior pole is examined by direct ophthalmoscopy. The anterior segment is evaluated by torch light and +20 or +10 D lens. A separate and pre set school screening form is used to record the findings. A referral letter to the parents is written for each student requiring hospital follow ups. The information of the students having abnormality is shared with the school administration and is asked to inform and motivate the parents for hospital follow ups and to use the prescribed therapy. The referral criteria and the screening techniques are based on the modified clinical technique and Indiana school vision screening guidelines given by Indiana optometric association. Results

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The first session of little optometrists was started on 11th October 2007 on the auspicious occasion of world sight day 2007. The first session formally ended on July 2008. Four schools (two from Kathmandu and two from Bhaktapur district) were included. The total number of students in the schools was 1728. Total students trained for little optometrists were 74. The students were from class 7, 8, 9 and 10. Regarding screening total of 1728 students were screened in four phase. Single phase targeted screening was done in each school. There were 967 (55.96%) males and 761 (44.04%) females in the screened population. The age range was 3 years to 22 years There were 258 students with abnormal conditions related to eye and vision which accounted for 14.93% of total screened population. Among them 63 students (24.44%) required hospital referral. Among the students with ocular and visual abnormalities, Binocular vision related problems were found in 35 students (13.93%), suspected glaucoma in 24 students (9.30%), conjunctivitis and conjunctival disorders in 35 students (13.56%), refractive error in 123 students (47.67%), lid and adnexa related abnormalities in 15 students (5.8%) and others, including congenital abnormalities, in 28 students (10.85%). Three cases of chorioretinal scars, one case of suspected disc edema and a case of ocular injury with pencil were also found during the screening. No cases of vitamin A deficiency were found. The diagnosis of amblyopia was not made during the screening itself, but the suspected students were referred to the hospital for detailed evaluation. It was confirmed at hospital after detailed examination and cycloplegic refraction. The visual acuity testing ability and detection rate of manifest ocular abnormality by the little optometrists was found to of high ranking. The difference in visual acuity taken by optometry students and little optometrists was less than one line of Snellens chart. The little optometrists were found to detect the large angle strabismus, red eye, corneal opacities and ptosis easily. Beside little optometrist program, NOSS is conducting separate school screening program within and outside Kathmandu valley. These screenings were done Kathmandu, Lalitpur, Bhaktapur, Kavre, Sindhupalchwok, Dhadhing and Ramechhap districts. This program also included screening for adult population. The screenings were also done at Down syndrome association, cerebral palsy association, deaf schools, many orphanages and asylum for elderly. Total of 6466 students and children were screened (not including adult population) in this program till now. The data of this program is yet to be analyzed. Discussion The program was launched on the world sight day 2007 and its first session was concluded in a program to celebrate the glorious first decade of optometry in Nepal. 55 | P a g e

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The little optometrists trained during this period have proven to be highly efficient in detecting the visual morbidity in school students. Currently 74 little optometrists are working in their school and society in Katmandu and Bhaktapur district through four Vision Club headed by them. No previous study or program was developed to make the school able to detect and refer the students with the visual problems. This program has set a system so that the students will be screened by the little optometrists and be referred if required every year or so. At this time when the effectiveness of pre-entrance eye screening programs for school age children is still controversial, the screening program by the school students may fall in debate. In contradiction to the previous study and the population census of Nepal 2003, male students were more in number than female students (55.96% males and 44.04% females). The results showed that 14.93% of the total school students had visual and ocular abnormality. In a similar study done on 2003, Adhikari S has found 12.3% of visual morbidity in school students.5 As a significant finding, this program has shown that among 258 students with ocular and visual abnormality, 63 students (24.44%) required hospital referral for further evaluation and management. Refractive error was the most common ocular problem prevalent among school children. It accounted for 7.5% of the total. Similar pattern was reported by Adhikari S5 and a Chinese study6 but a study conducted in Mechi zone in 1999 had found refractive error in school going children to be less than 3%7. The commonest refractive error in this study was myopia including myopic astigmatism (5.26% of total population). Hyperopia including hyperopic astigmatism accounted for 1.85% of total students screened. These findings are similar to the results of Adhikari S5 (myopia 7.2% and hyperopia 1.4%) Strabismus and binocular abnormality was found in 2.02% of these total children. It is reported little higher than by Adhikari S (1.6%)5 since beside strabismus; non-strabismic disorders are also included in this study. Glaucoma suspects were found in (1.3%) of total students which is slight more than in other studies. The prevalence of Lid and adnexa related problems (0.8% of total students) and conjunctival disorders (2.02% of total students) were found in consistency with the similar study in Nigeria.8 Other prevalent causes of ocular in our school were traumatic eye injury (0.057%) and other congenital posterior pole disorders (0.23%) of total students. These findings are slightly less than the results of the study done by Adhikari S5. Almost 98% of all visual disability in school children is preventable or treatable. Conclusion

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This program has shown that the trained school students can be used for basic screening at school. This can be helpful for early detection, referral and management of the prevalent visual disorders in children. The refractive error was the most common visual disability in school children. Hence early detection and management by appropriate glasses can prevent children from being visually handicapped. Strabismus and binocular disorders were second leading cause of ocular morbidity leading to poor school performance and even to permanent visual disability. So, early detection of strabismus is mandatory. Other problems found in school children were either preventable or treatable. Timely detection and intervention could save children from blinding complications. The trained school students such as little optometrists can be utilized for early detection and referral for proper management. Future plans NOSS is planning to conduct KAP (Knowledge, Attitude and Practice) study on eye health in school students before and after little optometrist training in its second session. The governmental schools and the schools out side the Kathmandu valley will be involved. Limitations of the program The program was started solely by the students of Bachelor of Optometry at Institute Of Medicine, TU. The schools included in the program were private and community schools within the Kathmandu valley. The government school could not be involved. The schools of rural area and outside the Kathmandu valley were not included. In most of the places glasses for refractive correction and medicines for pathology could not be provided due to deficient source. The data could have been collected more detailed and analyzed on scientific basis. The lack of research knowledge is the major cause. Technical aspect is the major problem faced during this program. Very less number of ophthalmoscope, retinoscope and trial set caused the screening program to take longer time on the day of screening. The financial aspect is also weak and the program is run by the voluntary support of the optometry students. Acknowledgements We express our heartfelt thanks and gratitude to Prof. Madan Prasad Uppadhyaya, Chairman, BP Eye Foundation for his invaluable guidance and advice. We are very grateful to Prof. Jeevan Kumar Shrestha, Director, BPK Centre for Ophthalmic Studies and all the administrative staffs of BPKLCOS. We are grateful to Mr. GS Shrestha, optometrist and Mr. Prakash Adhikari, optometrist for their help and advice during the 57 | P a g e

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program. We would like to thank The Rising Rays School, Putalisadak, The Rays School Bhaktapur, Genuine School Bhaktapur and Nagarjuna Valley Academy, Kathmandu for their active involvement and support during the program. We are obliged to the program coordinators Mr. JN Bist, Mr. Rajendra Gyawali, Mr. Raju Kaiti and Ms. Sonisha Neupane. We are deeply indebted to all the optometry students without whose support this program would not have succeeded. We wish to thank all who have always been supportive, wonderful and helpful to us during the program and we hope the support will last in future also. Reference
1. R. Beaglehole, R. Bonita, t. Kyellstrom. Basic Epidemiology. Geneva: World Health Organization; 1993 2. Wilson, JM.; Junger, YG. Screening for disease. Geneva: World Health Organization; 1986 3. Rahi, JS. Measuring the burden of childhood blindne. Br J Ophthalmol. 1999;83:387-388 4. Gyawali R. School screening: a step towards brightness. The sight.2007;1:41-42 5. Adhikari S, Nepal BP, Koirala S, Sharma AK. Ocular morbidity in school children in Kathmandu. Br J Ophthalmol 2003;87:531-4 6. Jialing Zhao Xianjin Pan, Ruifang Si, et al. refractive error study in children: results from Shunjin District, China. A. M. J. Ophthalmology. 200;129:427435 7. Pokhrel, GP; Negrel, AD; Munozz, R. et al. Refractive error study in children: results from Mechi zone, Nepal. Am J Ophthalmol.2000;129:436444 8. BO Adegbehingbe, MK Oladehinde, TO Majemgbasan, HO Onakpoya, and EO Osagiede. Screening of Adolescents for Eye Diseases in Nigerian High Schools. Ghana Med J. 2005 December; 39(4): 138142 9. Indiana School Vision Screening Guidelines, Third Edition 2000 10.National Association of School Nurses, 1995 11.Ohio Vision Manual, Rev. 1998

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Understanding Malingering
Baburam Bhattarai, B.Optom 10th Batch
Malingering is the classification of behavior but not an illness. For e.g. playing dead, like opossum, may save soldiers life. A case defendant may feign mental illness to obtain mental hospitalization rather than execution. A pilot may not report of syncope or migraine headaches, so that he could fly. Generally, malingerers pretend to be ill or injured in order to avoid work. It may be further inclusive of copy, imitation, feigning, simulation, imposture, artifice, counterfeit disease, goldbricking, scream shaking, factitious disorders and pathonomias. Malingerers seeking compensation often choose an event that commonly results in disability. They mainly express vague & ill defined symptoms. So, malingering is an intra-psychic & interpersonal behavior that includes care soliciting motive to obtain attention, love, sympathy, medial treatment & self punishment for guilty feelings. States of Malingering: 1. Simulation: Feigning of non existent disease 2. Exaggeration: Worsening of symptoms. 3. False-attribution: Assignment of other disease than original. 4. Dissemination: The pretending of non existent disease for insurance or job Hysteric patients are also malingerer but at their subconscious level. Hysteric doesnt exaggerate symptoms. Hysterical amblyopia is detected by charting of visual fields in which symmetrical (tubular) patterns are obtained with sharp margin. Psychological assessments of malingerers will reveal their aggressiveness, uncooperative nature and dramatizing abilities. Various vision tests can be assessed in which these persons will read every line hesitatingly. Treatment would get more complex with increasing number of visits, whereas placebos can make out. Different vision tests useful for the detection of malingering are: Binocular alignment, Objective prism, Prism stairs test, Bar reading test, Duanes method, Double prism test, Synaptophore test for one eye. Similarly, Jacksons convex & concave cylinder test, Special test cards, Mirror test, Amblyoscopic test, Cycloplegic test for partial blindness. On the other hand, Menace reflex & Optokinetic nystagmus test reveal malingering of blindness in both eyes. Hysterics enjoy the examination. Malingerer is aggressive, sulky & resentful of any tests.

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Optometrists are therefore well advised to limit his/her professional testimony to the fact that if there are no objective findings to confirm the patients complaints. Emotional stress creates problems subconsciously or at a conscious level which is the main cause. We should understand that blindness is not only an inability to see but also NO DESIRE TO SEE We, as an optometrist, must understand the human being of which the eye is a small part. Thoroughly understanding just a human eye is not enough.

Age Related Macular Degeneration: From the Desk of Optometry

Ajit Kumar Thakur B. Optometry, Final year Age related macular degeneration is leading cause of blindness in patient of age 65 or over in western world [1, 2]. It is the major challenge in the new millennium in the developing countries also, as the size of elderly population continues to rise due to betterment of medical facilities and increased life expectancy [3]. Its prevalence rises from 0.7% in the 6574years age group to 5.4% at 7584 years and 18.5% in people over 85 [4].Thirteen percent of those over age 65 have some form of visual impairment[5]. ARMD was found to be second only to cataract as the cause of severe visual loss even in Asian countries [5]. Almost 8% have severe impairment (blindness in both eyes or inability to read newsprint even with glasses)[6].It accounts for 50% of new cases of blindness in Canada.[7] ARMD is a disease of multiple etiologies, resulting in loss of central vision. The common atrophic or dry form accounts for 90% of ARMD but rarely results in vision loss greater than 20/80. Wet, exudative or disciform macular degeneration accounts for 10% of the total burden, although 90% of those with blindness (acuity less than 20/200) have this form [8]. If early macular changes (presence of any drusens) are included, the prevalence is 35% by age 64 and 50% by age 85. Risk factors include hyperopia, positive family history .smoking, blue eyes and chemical exposure at work [9]. It is far more prevalent in white than in black people due to relative protection from melanin pigment in black [10]. It is not clear which individuals with drusen alone will develop exudative or potentially serious changes, however, pigmentary changes, confluence of drusen and exudative changes in one eye, all increase the risk. Early symptoms include metamorphopsia or distortion of shapes, most easily recognized by viewing rectangular objects such as doors or windows Clinically ARMD is classified as 60 | P a g e

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a) Dry ARMD a. Characterized by large or soft drusen (63 micro meter) b. Areas of hyper pigmentation associated with drusen but excluding pigment surrounding hard drusen.(175 micrometer) b) Wet ARMD a. Characterized by choroidal neovascularization b. Retinal pigment epithelium detachment c. Vitreous hemorrhage d. Visual Acuity is deteriorated less than 20/200 e.

There is no universally accepted definition of ARMD. Age-related Eye Disease Study categorized ARMD into 5 groups.

Classification of ARMD (age-related eye disease study[11]

Category Clinical features Category No drusen or non-extensive small drusen only in 1 both eyes Extensive small drusen, non-extensive Category intermediate drusen, or pigment abnormalities in 2 at least one eye Large drusens, extensive intermediate drusens, Category or no central geographical atrophy in at least one 3 eye Category Geographical atrophy in at least one eye 4 Category (Neovascular) evidence suggesting CNVM or RPE 5 detachment, (serous/hemorrhagic) in one eye Management Laser Photocoagulation-[12] It has been shown beneficial only for well defined lesion. Studies shows that the benefits of argon laser photocoagulation are greatest in 1st post treatment area. A study shows the treatment benefit persisted over 5 year follow up. 64% of treated eye progressed to severe visual impairment which is significantly smaller compared with control 94%. Photodynamic therapy-[12] 61 | P a g e

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A recent study showed that photodynamic therapy with visudyne reduces the risk of moderate vision loss in patient who presented with sub-foveal lesion in ARMD predominantly classic chorioneovacularized area. PDT use intravenous injection of photosensitizing drug combined with a low intensity laser light to cause damage choroidal neovascularization through photodynamic reaction by light activated drug Low vision management Low vision is a rehabilitation service. This helps the disabled people to proceed their life independently. Over 65 year age is unproductive age and again the loss of vision at that adds extra burden to family as well as society. Making them at least independent in doing their activities during daily life will help to enhance the country economical status as well. During low vision management, the fore most things kept in mind is patients need. Low vision examiner needs to enquire the patient hobby, patients difficulty very closely and specifically. This helps the examiner to set the management plan in one study done in BPKLCOS by myself, out of 32 patient, 21(67.6%) had difficulty in recognizing face, 11(32.4%) complained of difficulty in watching television. For near the chief complaint was reading holy book print, reading news paper, coin identification. Only 5(14.7%) people complained of difficulty in mobility in unfamiliar places. in writing skill, only 4(11.8%) out of 32 complained of trouble in writing in straight line.19(55.9%) had difficulty in doing their daily activities .5(14.7%) complained of having glare problem in sun. After taking complete history and knowing the need of patient, visual acuity for near and distance and in low contrast chart is taken. The presenting visual acuity is how much lesser than the required visual acuity to accomplish visual demand is calculated and with the help of optical and non optical devices, the target is tried to achieve. The same study shows the presenting visual acuity binocularly for distance as 0.920.43Log Mar (MeanSD) ranging from 0.4-2.50 Log Mar. The Visual acuity with 10% contrast Log Mar chart shows 0.990.48 Log Mar ranging from 0.5-3.00 Log Mar. The near Visual acuity was found to be 3.042.09 M ranging from 1.00-10.00 M unit. Refraction is done to correct the refractive error prior to giving magnification. If magnification is given for unfocussed image, image will loose contrast and detail. 6 out of 32(18.8 %.) was found to be myopic .9(27.1%) was found to emmetropic and 17(53.9%) was found to be hyperopic. Visual acuity after refraction was found to be 0.820.38 (0.4-1.6) with improvement of 0.11 Log Mar. Telescope was tried on 23 out of 32 (67.6%) patient tried on top of refractive correction with mean magnification of 3.661.34X (2.50-6) X. the visual acuity improved to 0.440.28 (0-1) Log Mar with improvement by 0.44 log units from presenting Visual acuity. Out of 23 on whom telescope was tried 12 preferred the device and took it with them feeling it would help them in doing work independently. 62 | P a g e

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For near vision ,spectacle magnifiers ,hand held magnifiers , and spectacle magnifiers of similar magnification were tried .The near visual acuity with Spectacle magnifiers was found to be 1.120.7(0.0-3.2).with hand held magnifier was found to be 1.240.73(0-3.2),and with stand magnifier was found to be 1.170.68(0-3.2).16 out of 32 (50%)preferred spectacle magnifiers,8 (25%)preferred stand magnifier,2( ) preferred hand held magnifier,3 people preferred both spectacle and hand held magnifier. Non optical advises that help in patient with age related macular degeneration includes training on eccentric viewing, bright illumination in room, filters for glare control, reading stand, writing guides etc. In my study .almost all (29 out of 32)91% visual acuity was subjectively better on eccentric viewing.30 out of 32(93.75% preferred fluorescent light to incandescent one.3 out of 32 (9.4%) was prescribed with photo chromic glasses. It is seen that through low vision service, there is significant improvement of visual performance and the patient has little difficulty during their daily activities after the use of low vision devices. As the definitive treatment for age related macular degeneration is still to come, optometrists are the best option to refer a case of ARMD for betterment of life style of the senile people. References
1) Evans J. Wormald R, Is the incidence of registrable ARMD increase?, British Journal of Ophthalmology1996;80:9-14 2) Harvey DT. Common eye disease of elderly people; identifying the treatment and cause of vision, Gerontology 2003;49:1-11 3) Mitchell P. Smith W. Attebok ,Prevalence of ARMD in Australia, the blue mountain eye study,Ophthalmology1995;102:1450-1460

4) HO T, Law N.M,Guh Luetal, Eye disease in Elderly in Singapore, Singapore Med Journal1997;38:144-146 5) Christopher patterson ,MD 6) Screening for visual impairment in elderly 7) Age related eye disease research group. Risk factors associated with age-related macular degeneration. A case control study in the age-related eye disease study. Age related eye disease study report number 3. Ophthalmology 2000; 107 : 222432.

8) . Frank RN, Puklin JE, Stock C, et al. Race, iris color, and age-related macular degeneration. Trans Am Opthalmol Soc 2000; 98 : 109-15 9) .Age related eye disease research group. Risk factors associated with age-related macular degeneration. A case control study in the age-related eye disease study.

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Age related eye disease study report number 3. Ophthalmology 2000; 107 : 222432.

Children in clinic: A challenge

Sanjay Marasini B. Optometry Final Year Children are fidgety. They do everything for the fulfillment of their demands, whether it might be by crying, quarrelling, or others. They want to get their parents sympathized to fulfill their wishes. Its natural to find children in this mood. When a child enters a clinic, the environment around attracts him. He finds everything differing from his known surroundings. Big instruments, different people in white coat and obviously different faces in-front of him makes him feel scary. So, examining a child in a clinic is very challenging to disclose the clinical findings and address the parents complains. If we can set aside a little time from our busy schedule, we can get most of the information a clever child has. The foremost step is to familiarize the child and to behave with him as if you know him for a long time. Handshaking, calling by his name, imitating his actions, positive comments on his look and make him express something makes the situation comfortable. Once the child starts talking something, you are almost 50% done. Children naturally have short span of attention and the situation becomes more complicated when the child has Downs syndrome, Cerebral Palsy or other central nervous system disorders. In such a situation, the clinician can gather information very cleverly in a short time looking for the childs head posture, facial expression on close up, response to the surroundings and so on. These things tell the visual behaviors of the child. Moreover, the history of parents on childs visual behavior (does the child stare at face and smile, does he respond to bright colors etc.) is important before modeling a definite diagnosis. Various types of visual acuity testing methods are developed that are intellectually suitable to the different age groups of the children. Preferential looking charts readily quantify the visual acuity without active co-operation of the child. The children readily memorize the Snellens chart so the acuity determined might be misleading. Multiple Snellen Optotype is a good choice when using Snellen chart. Assessing Extra-ocular motility is still a more difficult task. A colorful object moved in different gaze positions can give some results but as the child tends to rotate head, findings may not be accurate. For very young children, dolls head test can be used to assess the versions. To rule out the strabismus, different test methods are developed. If the popular tests like cover test and prism cover test cannot be done, Hirschbergs test or Bruckners test can be considered. The results will be fine if the Bruckners test is done under mydriasis (But remember; 64 | P a g e

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Hirschbergs test be done under normal papillary condition). Furthermore the head positions and chin positions can give better clue regarding the presence of strabismus. The history on the duration and onset of abnormal head position plays a significant role to rule out some of the conditions like congenital fibrosis of the Sternocleidomastoid muscle where the child may have abnormal head position. It may be necessary to look for it when the stubborn parents suspect the ocular conditions and when no any fruitful diagnosis is pored over. Flying baby position although advised for slit lamp examination, it seems to be difficult most of the time. Torch light examination can reveal most of the anterior segment disorders .For the posterior segment evaluation, direct ophthalmoscopy can be done when the child is asleep or binocular indirect ophthalmoscopy can be easier when holding the limbs and head of the child still forcefully. Retinoscopy should be carried out always under full cycloplegia so that the fixation of the child doesnt take into account on the refractive findings. The child when asleep makes the examination much easier. Sometimes the child closes eyes while throwing light into his eyes. This time producing some alarming sounds attracts his attention. The stinging sensation of the drops further increases the distance between the clinician and the child when dilating the eyes. Person other than clinician can help putting the drops when the clinician is not present on the spot. When the child tries to avoid drops sometimes it is necessary to put some drops on the childs skin and make him feel that the drop doesnt have any sensation. But beware! This doesnt work second time; the child may kick you out! Visual field testing can be done with the child sited in parents lap and facing the examiner attracting his attention while the hidden person from back slowly moves a bright colorful target from unseen areas. The child will move his head to see that colorful object when it approaches the visual field boundary. The knowledge on theory and practice on the related field only does not always help the clinician to address the problem. Common sense, patience and ability to cope with different humane nature almost ensures gathering of all the valid information of the most stubborn children.

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Untreated Amblyopia: - The impact on life

Gopal Bhandari B.Optom 7th Batch Amblyopia (literally blunt sight) is potentially remediable visual loss, usually affecting one eye, arising from an insult (or insults) to the developing visual system in early life. Von Noorden has given a comprehensive definition of Amblyopia as a unilateral or bilateral decrease of visual acuity caused by pattern vision deprivation or abnormal binocular interaction for which no cause can be detected by the physical examination of the eye and which in appropriate cases is reversible by the therapeutic measures. Amblyopia is the most frequent cause of monocular visual impairment in both children and adults. The reported prevalence of Amblyopia range from 1% to 6.1% depending on the age group studied and the visual acuity criteria used. The early detection and treatment of Amblyopia is essential to restore normal vision in children. It is necessary to conduct the pre-school and school vision screening programmes to detect the potential risks of Amblyopia and treat them within the critical period so that normal binocular vision can be established. To perform pre- school and school screening for all the children to detect Amblyopia is a very difficult task and moreover the treatment after detection is challenging. Since Amblyopia mostly results monocular visual impairment the question arises what is the risk of not treating Amblyopia? Is it really necessary to detect and treat Amblyopia? These are the questions need to be answered. So in order to discuss the cost effectiveness of screening and treatment of Amblyopia the possible functional disability related to unilateral Amblyopia must also be taken into consideration. Childhood vision screening still remains both a critical and controversial matter. In 66 | P a g e

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order to evaluate if pre school/school screening is worth while from a population point of view many issues need to be clarified, first the life time risk associated with untreated Amblyopia must be established and second the total cost of screening and treatment and the actual benefit of a screening program to the population must be answered. So it is necessary to discuss the following various negative impact of the untreated Amblyopia. Increased risk of Bilateral Visual ImpairmentThe most concern about the untreated Amblyopia is the devastating bilateral visual impairment suffered by the people if there is loss of vision in the good eye. There is increased risk of individuals with Amblyopia losing the felloe eye and become visually impaired as compared to one without Amblyopia. A study done by Rahi et al, where the projected lifetime risk of vision loss for an individual with Amblyopia was reported to be 1.2% and the other study by Van Leewen et al reported the life time risk of bilateral visual impairment to be as high as 18% for with Amblyopia, compared with 10% for non amblyopic subjects. So it is clear that the untreated Amblyopia almost doubles the lifetime risk of bilateral visual impairment in an individual. Impaired Binocular single visionHaving two eyes functioning normally and in synchrony is crucial to human beings. Amblyopia that cause impairment of one eye and disrupt the binocular vision, would impact a disability. The benefit of having two eyes should be clear in order to know the consequences of impaired vision in one eye. Two eyes functioning well will have a benefit of binocular summation. Binocular visual performance exceeds the monocular. The binocularly tested visual acuity is better than that tested monocularly. From many experiments of binocular summation it is estimated that improvement of sensitivity under binocular condition is 1.4 times (40%) that of monocular viewing. Amblyopic individual devoid of such summation is less sensitive and have reduced visual performance as compared to nonamblyopic. Reduced stereopsis, the binocular perception of depth based on retinal disparity is generally accepted to be the major disadvantage of untreated Amblyopia. Steroacuity is considered as a bench mark for peak clinical performance of binocular vision. Individuals with reduced stereopsis will have disadvantages in situation requiring spatial certainty. Binocular vision facilates control of manipulation, reaching and balance. People without stereopsis have difficulty performing tasks that relay on three dimensional visual clues. Individuals with reduced stereopsis have problem misjudging distances, problem with eye- hand co- ordination and perceptual difficulties so that to all untreated amblyopic golf players all greens are flat. Impact on employment prospectus Certain occupation does require a high level of visual performance and defective vision in one eye precludes entry. There are many such professions where fine vision in both eyes is mandatory. Occupations involved with driving, navigating, piloting, armed forces and surgeon are 67 | P a g e

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some where binocular vision is important. Stereopsis, reduced in Amblyopia is necessary in flying ability, especially in unfamiliar and stressful condition like assessing ground proximity at the time of landing, and in adverse weather condition. Amblyopic individuals have reduced driving performance with increased chance of accidents. Fine eye hand co- ordination and well developed binocular single vision is essential for surgery. It is more important especially for ophthalmological surgery that requires great precision. A surgeon with binocular vision can perform more effectively compared to those lacking fine stereopsis due to untreated Amblyopia. So an untreated amblyopic individual has to compromise in his/her career choice which is one of the negative impacts of the Amblyopia being untreated. Impact on psychosocial developmentRecent studies have shown that untreated Amblyopia affects psychosocial development of an individual. In the study done of Packwood et al 1999, 52% reported interference with education, 48% reported interference at work, 50% at lifestyle and 40% on sports. Apart from this, individual with Amblyopia experienced more distress in areas of somatization, obsession, compulsion, interpersonal sensitivity, anxiety and depression compared to non amblyopic. Amblyopia apart from reduction of vision in one eye has far more impacts as compared to normal. The untreated Amblyopia has many more consequences that affect the quality of life of an individual. So by detecting and treating Amblyopia on time we are able to prevent an individual from being at high risk of Binocular visual impairment, compromise in career choices due to lack of vision in one eye, reduced quality of life due to decrease in visual performance and so on.. So now the cost effectiveness of detecting and treating Amblyopia early in life cannot be questioned. The Pre School and school screening program need to be encouraged to detect and treat as many Amblyopia as possible. Let no body get blind as consequences of untreated Amblyopia. References1. Binocular vision and ocular motility, Von Noorden GK 2. Foundation of binocular vision, Scoot B. Steinman 3. Amblyopia, a multidisciplinary approach, Merrick Moseley 4. Researches.

Vitamin A Deficiency: A Public Health Problem

Deepak Adhikari BPH 19th Batch Vitamin A is an essential micronutrient involved in a number of biochemical activities necessary for normal biological function, including vision, immune-competence etc. Because of its role in maintaining immune-competence, Vitamin A deficiency ( VAD) cause an increased risk of morbidity and even mortality, which in turn depletes bodily stores of 68 | P a g e

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vitamin A resulting in a vicious cycle of deficiency and deficiency and diseases.1 The depletion of vitamin A stored in the liver leads to clinical xerophthalmia. Xerophthalmia has been classified by WHO (1982) with increasing severity as follows: XN : Night blindness X1A : Conjunctival Xerosis X1B: Bitots Spot X2: Corneal Xerosis X3A: Corneal Ulceration X3B: Corneal Keratomalacia XS: Corneal Scar XF: Xerosis of Fundus1 WHO (1982) has fixed the following criteria for determining the public health significance of xerophthalmia and vitamin A deficiency. Prevalence criteria (in percentage of preschool age population, 6 months to 6 years old, at risk) Night blindness: > 1% Bitots spot: > 0.5% Corneal Xerosis/ corneal ulceration / Keratomalacia: > 0.01% Corneal scar: > 0.05 % 1 Vitamin A deficiency: Summary of Major National Survey findings 2 Survey Year Age group Prevalence (%) X1B XN Nepal Blindness Survey 1980/8 0-6 years 0.64 0.37 1 Nepal Multiple Indicator 1995 24-36 months 0.9 Survey Nepal Family Health Survey 1996 6-36 months 1 Pregnant 18 Nepal Micronutrient Status 1998 Mother having 4.7 Survey preschool children 12-59 months 0.27 6-59 months 0.33 School Age children 1.9 1.2 Similarly, the overall prevalence of sub-clinical VAD (Serum retinol levels < 0.70 mol/l) is 17 percent for women and 32 for pre school children. Besides this national level survey several small scale surveys have confirmed that VAD remained a significant nutritional disorder and a major public health problem. It has been estimated that twenty thousands preschool children aged 6-60 months, in Nepal would be at risk of dying annually due to the 69 | P a g e

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consequences of vitamin A deficiency in the absence of any intervention to improve Vitamin A status. Globally, vitamin A deficiency is compromising the immune systems of approximately 40% of the developing world's under-fives and leading to deaths of approximately 1 million young children each year.3 Government response to Control VAD: Nutrition specific Millennium Development Goals: Reduce sub-clinical VAD to 7% by the end of 2015. The government has set the objectives to virtually eliminate vitamin A deficiency and sustain the elimination by the year 2017. 5 Government has implemented a combination of food-based strategies and periodic high-dose supplementation to improve the vitamin A status of the population. To achieve this goal and objectives government has set the following strategies:4 Distribute high -dose vitamin A capsules to children between 6 - 59 months biannually through FCHVs; Advocate for increased home production, consumption and preservation of vitamin A rich foods at the community level; Explore the fortification of suitable foods ( such as sugar and cooking oil ) with vitamin A; Strengthen the usage of vitamin A treatment protocol; Supplementation of vitamin A capsule (200000 IU ) to postpartum mothers through healthcare facilities and community volunteers; Treatment of night-blind pregnant women with low dose vitamin A capsule (25000 IU) through healthcare facilities in selected districts; Achievement: From the past three year all the children (100%) age 6-59 months have received two dose of vitamin A supplementation per year.4 According to NMSS 1998, prevalence of Bitot's spot and Night blindness are below the WHO cut-off points to designate a significant public health problem indicating towards the goal of VAD elimination at the national level.2 With the continued efforts from the all government and nongovernment sectors the VAD will not be any more public health problem in Nepal.

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References:
1. Adhikari R.K. and Krantz M.E. Child Nutrition and Health Third edition 2001, Health Learning Material Centre, Kathmandu, 268. 2. MoH, UNICEF, WHO, The MI, New Era; Nepal Micronutrient Status Survey 1998. 3. UNICEF, The MI; Vitamin and Mineral Deficiency A Global Progress Report, 2003. 4. Department of Health Service Kathmandu, Annual Report 2063/64. 5. Government of Nepal, Ministry of Health and Population Department of Health Services, Child Health Division, Nutrition Section; Nutrition Training Module 2064.

Drug induced oculotoxicity

Nirmal Marasini B.Pharm Fourth year (5th batch) A large number of medications associated with eye have its toxic effect. Toxic effects range from less serious to very hazardous conditions such as loss of vision. Drug administered systemically or topically produces adverse effects on the eye and surrounding tissues. Adverse effects of drugs may involve external and internal ocular structures. External ocular structure Eyelids and peri-orbital structures: Primary toxic effects of drug in the eyelids are discoloration, edema and altered eye position. Drug associated with periorbital pigmentation: antiarrthymic drugs, amidarone ,antipsychotics, chlopromazine and other phenothiazin. Drug associated with periorbital or eyelid oedema: Nifedipine, Sulphonamide Drug associated with ptosis include: Barbiturates, Bretlium, Phenytoin, Chlorquine, Polymyxin-B and Vinca alkaloid. OCULOMOTOR FUNCTION Drug associated with broken pursuit movement and nystagmus: anticonvulsant-phenytoin, phenobarbitone. Drug that produces oculogyric crisis: Dopamine blockers like Antipsychotics 71 | P a g e

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Drug associated with cranial nerve palsies: Nalidixic acid, Corticosteroids, Ethanol, Vincristine etc. Lacrimation: Adverse effect is associated with both hyper and hyposecretion. Drugs that Decrease tear secretion are: Anticholinergic drugs, Tricyclic, Antidepressants, Antihistaminics Increased tear secretion: Cholinergic drugs, Methotrexate, 5-flurouracil. Increased tearing is frequently associated with drug induced corneal and conjunctival inflammation and irritation after severe inflammation as might occur in Steven Johnson syndrome. Scaring of the conjunctiva may result in dry eye from damage to the tear component producing cells and glands. Conjuctiva and cornea: Major toxic effect are conjunctivitis, keratitis or keratoconjuctivitis, and formation of deposits or pigmentation in conjunctiva or cornea, severe inflammation of the eyelids, conjunctiva and cornea. Commonly used medication associated with allergic conjunctivitis and keratoconjuctivitis include Chloralhydrate, Sulfa drug, Phenytoin, Salicylate and other NSAIDs Prolonged therapy of certain medication may result in the formation of deposits or opacities in the conjunctiva or cornea. Conjunctiva deposit has been reported with prolonged therapy (longer then 10 years) with Tetracycline for acne vulgaris. Other medication associated with conjunctival deposit or discoloration including Amidarone, Gold salt, Iron supplements, Quinoline derivative and Penicillamine. Internal ocular structure Unlike many of the adverse effects on external ocular structures, adverse effects in internal ocular structures may produce serious irreversible impairment of vision. Adverse effects include drug induced glaucoma, cataract, retinopathy and optic neuritis. Lens: Major adverse effects in lens are cataract, and myopia. Commonly used medication that produce cataract with significant frequency include the Corticosteroid, Phenothiazine, ,Amidarone ,Gold salts and topical Parasympathomimetic agents used in the treatment of glaucoma. The risk of producing steroid cataract is very high (75%) if the equivalent of more than 15 mg of Prednisolone is given for several years. Para-sympathomimetics and narcotics produce myopia because of ciliary muscle contraction. Myopia as a result of lens hydration is induced by 72 | P a g e

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Corticosteroids, Metronidazole, Tetracycline, Sulphonamides, Thiazide diuretics, Spironolactone and Acetazolamide. Uveal tract: A large number of medications alter the function of iris (Mydriasis or Miosis) and ciliary body (alteration of accommodation) through direct pharmacological effect. Such agents include Cholinergics, Anticholinergics, Opiates and Adrenergic agents. Retina and optic nerve Toxic effect of the sensory retina and the optic nerve are the most important effect of drug on eye. The mechanism of drug induced retinal toxicity are variable and may involve direct toxic effect, accumulation of drug in retinal structure, ischemia secondary to effects of retinal vasculature or immune reactions. Commonly used medication producing significant retinal toxicity include; Phenothiazine, 4AminoQuinoline (Antimalarials), Tamoxifen and other neoplastic agents and Deferoxamine. Retinal detachment has occurred in susceptible individuals and those with retinal disease; therefore fundus examination is advised before treatment with these drugs. Adverse of drug on the optic nerve and visual tract include; Optic neuropathy, Optic atrophy, Retro bulbar Neuropathy, Papilloedema. Optic Neuropathy; an inflammation of the optic nerve produces symptoms including blurred vision, constricted visual field, altered color vision and occasionally oedema or hyperemia of the optic disc. Ethambutol produces two types dose dependant Optic neuropathy (Axial or paraxial) after three months therapy in tuberculosis. Axial is more common characterized by decreased visual acuity, central scotoma and red-green color vision deficiency. Ethambutol induced Optic Neuropathy can resolve within three months of drug discontinuation. Long term therapy of Chloramphenicol also produces Optic Neuropathy. Chloramphenicol eye drop should be avoided because of risk of aplastic anemia .Other agents to produce Optic Neuropathy or Optic Atrophy include; Minoxidil, Cisplatin, Vincristin, Sulpha derivative, Metronidazole, Corticosteroids, Barbiturates etc. Drug induced Contact Lens Problems Interaction may occur between drug and contact lens(staining of lens by Rifampin, Rifabutin, Sulfasalazine or topical epinephrine)or lens solutions(Reaction caused by Tetracycline and Thimersol preserved solutions).Medication interfere contact lens users by decreasing lacrimation (Anticholinergic)increased lacrimation (Reserpine),corneal oedema resulting in poor lens fit (Estrogen),decreased acuity secondary to change in refraction(Myopia produced by Thiazide diuretics). Drugs absorbed into soft contact lens will result in prolonged corneal exposure to high drug concentration potentially increasing risk of toxicity. 73 | P a g e

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Acanthamobea Keratitis, a sight threatening condition is associated with ineffective lens cleaning disinfection or use of contaminated lens case. References: 1. Dipiro Joseph T, Talbert LRobert et al:Pharmacotherapy a Pathophysiologic
approach ,3rd edition ,Library of congress cataloging in-Publication data,USA. 2. Mehata Dinesh K:British National Formulary march 2006,BMJ publishing group and RPS publishing2006,London.

Differential diagnosis of some ocular symptoms

Raju Kaiti, B.Optom 9th Batch 1. Epiphora (excessive watering) -Hypersecretion of tears
Ocular irritation Drug induced Lacrimal gland tumors Metabolic disorders(hyperthyroidism, Parkinsons disease) Crocodile tears (aberrant innervations by salivary gland fibers)

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Psychic Hypersecretion Abnormalities of lid position(ectopion, lagophthalmos, etc) Failure of lacrimal pump mechanism Punctal stenosis or occlusion Lacrimal sac abnormalities(dacryocystitis, dacryoliths, polyps, tumors, Foreign bodies, trauma, fistula) Nasolacrimal duct obstruction External ocular inflammatory disease Uveitis Pharmacologic or traumatic mydriasis Aniridia Albinism Achromatopsia Cataracts(esp. Posterior sub-capsular cataract) Retro bulbar neuritis CNS disease esp. meningitis, subarachnoid, hemorrhages, rabies Exotropia Congenital glaucoma Corneal scar Corneal epithelial edema, esp. increased 10 b(glaucoma) Epiphora Cataracts Uveitis Posterior sub-capsular cataract

-inadequate drainage

2. Photophobia

3. Halos (appearance of different colours around light source)

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DACROCYSTOGRAPHY AND RECENT LACRIMAL IMAGING MODALITIES

Surendra Dhungana BSc.RT 6th Batch Institute Of Medicine /TU Ocean_sea99@hotmail.com

INTRODUCTION

Dacrocystography is a radiographic investigation of lacrimal system following the injection of contrast media. Dacrocystography is usually employed to demonstrate the site of obstruction in case of obstructive epiphoria. Tears produced passes into the lacrimal ducts via puncta and then into canaliculi. The ducts open into the lacrimal sacs and are connected to nasal cavity by naso-lacrimal ducts.

CONTRAST MEDIA

0.5 ml to 2 ml of water soluble contrast media per side is required, according to quantity necessary to fill the available space .The contrast injection is continued until reflux occurs from the upper punctum and patient tastes the contrast media in the pharynx.

EQUIPMENT REQUIRED
Skull unit. Silver dilator and cannula.

TECHNIQUE

Initially two preliminary films (scout films) in occipito-mental and lateral projection are taken so that we can compare these films with post contrast injection film and even to see any other pathological condition. The patient is asked to lie down in supine position and is asked not to blink during insertion of catheter or cannula. A drop of topical anesthesia can be placed into palpebral aperture if required for uncooperative patients. The lacrimal sac is massaged to express its contents prior to injection of contrast medium. Then the lower Sc: superior canaliculus punctum is diluted with silver lacrimal Ic: inferior canaliculus 76 | P a g e Ls: lacrimal sac ND: nasolacrimal duct VK: valve of Krause VH: valve of Hasner

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dilutor and cannula is inserted in the canaliculus. When the cannula is in the required position, contrast medium is injected and radiographs are taken as quickly as possible as contrast media remains for only about 15 to 30 seconds. Radiographs are taken as in for preliminary films (occipitomental and lateral projection). For lateral projection head is turned laterally; patient being in supine position, such that medial median sagittal plane is parallel and inter-pupillary line perpendicular to x-ray couch top and for occipitomental projection patient is turned into prone position with the chin raised and base line at 35degrees.

AFTERCARE
Local anesthesia if used during dilution of Punta lacrimalia and blunt cannula insertion leave the eye temporarily unprotected. An eye pad or goggle can be recommended as they leave radiology department. OTHER MODALITIES 1. Computed Tomography Dacrocystography (CTD) CTD require cannulation of one of the lacrimal canaliculi as in dacrocystography, precluding adequate functional evaluation of the lacrimal drainage. Delivery of ionizing radiation occurs with this technique and absorbed dose to the lens has been calculated, as 1.8 to 2.6 mSv for CTD. This procedure is time consuming, expensive, and not widely available. 2. Magnetic Resonance Dacrocystography (MRD) It is done after topical administration of diluted contrast media (gadodiamide dimeglumine) into the conjunctiva. MRD can also use stationery or slowly flowing water injected into lacrimal drainage system as substitute for contrast media and acquisition of heavily weighted T2 images. This process is also time consuming, expensive and not widely available. Its only advantage is that it doesnt make use of radiation. 3. Lacrimal Scintigraphy It allows more physiological assessment of tear flow dynamics .In this procedure technetium lebelled celloid is instilled in the inferior fornix of the eyes with subsequent imaging to demonstrate drainage. The absorbed dose to the lens has been calculated as1.09 mGy/MBq. This procedure is not easily practicable everywhere because of unavailability of radionuclide. References: American Journal of Radiology (www.ajnr.org) A Guide to Radiological Procedure - Chapman Diagnostic Radiography Glenda. J Bryan

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SPORT AND VISION

Suraj Upadhyaya Pokherel B. Optom 9th Batch A perfect vision is required for all kinds of professions. People involved in sports or a profession should have healthy sharp vision as demanded by those sports. Perfect vision in sportsperson means they can show a good performance in particular sport to develop professionalism. Vision cannot be perfect just having a visual acuity of 6/6 or no pathology involved. it is a dynamic state of balance and harmony fostered by the ability to identify , interpret , comprehend and act on what the eyes see. Perfect vision offers better quality of life with all the opportunities open for an individual and extracts the most exact one. Sport is one of the biggest and most diverse occupations. Sports can be defined as a physical activity involving large muscle groups requiring strategic methods, physical training and mental preparation and whose outcome is determined, with in a rule, by framework and skill not by chance. We all are focusing in working upon the physical ability of the athlete and their equipments to improve their sporting performances. But we always tend to forget our eyes which are the source of our vision. In all our reaction to the information, our eyes lead and the rest of our body follows. If the headway is weak in any of its elements, how can you expect the peak performance by rest of the factors If you can't see, you can't hit it. Originally, sport vision originated in U.S.A. The sport vision science actually started to develop in UK under the leadership of Mr. Geraint Griffiths since 1994. Probably he is the one who made systemic approach to sport vision science. Sport vision is a visual science which deals with visual performance and sports activities together. It deals with static visual acuity, dynamic visual acuity, eye movement skills, accommodation and vergence, depth perception, central and peripheral recognization, peripheral vision, eyehand-body co-ordination, colour vision, visual concentration, visualization, spatial location, binocular vision , night vision, glare, speed recognization, reaction time, etc. It also includes enhancement of ocular skills through

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vision training, protection from ocular injury and assessment and management of any sport related ocular traumas. Basically there are two categories of sports, dynamic like soccer, yachting, squash, hockey, ice-hockey, baseball, etc and non-dynamic sports like archery, bowling, shooting, dart, snooker, chess, etc. Dynamic visual acuity should be tested by the fitness test takers before appointing any player for a particular dynamic sport. In today's competitive world, stereoscopic binocular vision is very important. Binocular field of vision is about 30 more than the monocular field and contrast increases about 40% in binocular vision than monocular. Poor timing also seems to be associated with reduced stereopsis. If an athlete is constantly over or underestimating the distance of the target, poor depth perception may be the reason. This, in turn, may be because of uncorrected hyperopia and anisometropia. Accommodative vergence facility facilitates the speed of the eye to focus clearly and accurately at different distances which depends on the good oculomotor control and cognitive ability. Pursuit eye movement is very important in sports. for e.g. it would be much more difficult to trace a tennis ball accurately if head movements are necessary because the gross neck muscle are not as efficient as the finely tuned extra ocular muscle. The two primary visual skills of sports are aiming and anticipation. Aiming involves correct positioning of the sights in relation to location of the target. Focusing and convergence ability are the critical aspects of aiming. Anticipation is the ability of an athlete to block, hit or avoid a rapidly moving ball. The athlete anticipates the expected trajectory and the speed of the ball and then blocks it or hit it. Vision in sports is affected by many factors:1. Target size and its distance. 2. Speed of target. 3. Speed of athlete. 4. Contrast of the target against its background. 5. Colour of the target and its background. 6. Ambient light level. 7. Position of the luminaries. 8. Perception and wind speed. 9. Reflectivity of the playing surface and surrounding. 10. Environmental distraction like rain mist fog.

Football and cricket are the most popular and mostly played sports. A footballer needs sharp static and dynamic vision to see the ball, friends, 79 | P a g e

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goalpost and the sharp ground margin. To increase the precision during play, the player also needs good stereo acuity, spatial judgment, eye-foot co-ordination, etc. Cricketers require better visual skills since the size of the ball is even smaller. The visual skills for the cricketers include sharp and precise static and dynamic vision, stereo acuity, background and contrast, illumination level while batting anticipating the speed of ball, cocoordinating eye hand and foot to aim the bat to execute the shot and while fielding anticipating the direction of the shot to field the ball. In table tennis the average total time to react to a shot is usually around 0.25 sec. With lots of training and practice it can be reduced to 0.18 sec. All the visual skills are important in sports. The most important thing in sport is concentration, confidence, control and commitment. In the world where million of dollars are spent on various aspects of sports, there seem to be huge potential to explore the sport vision science to improve the sporting performance of our athletes. And the various aspects of sport vision science can only be obtained by sport vision specialist optometrist who specializes and is expert in prescribing and dispensing eye wear suitable to respective sports and prescribing them training regarding the various aspects of their visual system. Different professions led the foundation for development of behavioral optometry where specific visual need to specific occupation is evaluated. The future may bring the concept of both individuals and team appointing their own sport vision consultant (optometrist) in a similar manner to trainers, coachers, psychologists and physicians. And the involvement of eye care professionals in concern with sport authorities could constitute an accepted multi-disciplinary approach to sport vision. The future may see increased cooperation between manufacture, sport vision association, researchers and sport persons. The best way to improve the sporting skill is to rule out all the probable causes that may cause stress in any forms and result in poor performances. With the development of sport vision in the field of optometry, it is possible to set aside probable problems that may arise due to undetected visual disturbances.

References 1. Lectures by Vidyut Rajhans Lions NAB eye hospital, Miraj,India 2. Geraint Griffiths: Eye dominance in sport; a comparative study : The incidence of ametropia in elite sport : Visual performance in yachting 3. Donald F.C. loan: Sports eye wear; a survey of UK and USA practitioners

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4. Kishor Sapkota: Visual status in Nepal's national footballers and cricketers, 2004 5. Sport Vision by D.F.C. Lovan and C.J. Mac Ewen 6. Binocular Anomalies: Diagnosis and vision therapy by John R Griffen and J. David Grishan 7. Binocular Vision And Ocular Motility: Therapy and management of Gunter K. Von Noorden and E. Milio, C.Campos 8. Websites of: optometry: sport vision: eye works: sports eye site: info sports: American Scientist: etc.

HIV / AIDS & OPHTHALMOLOGY Dr Gyanendra Lamichhane Final Yr. Resident BPKLC OS 81 | P a g e

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During 1981, case of a rare neoplasm, Kaposi's sarcoma and pneumocystis carinii were reported in the USA in previously healthy homosexual men .This was the beginning of an epidemic eventually termed Acquired Immune Deficiency Syndrome (AIDS) .In 1984 the association between infection with HIV and development of AIDS was established. Since the first cases of acquired immunodeficiency syndrome (AIDS) were reported in 1981, infection with human immunodeficiency virus (HIV) has grown to pandemic proportions, resulting in an estimated 65 million infections and 25 million deaths. During 2005 alone, an estimated 2.8 million persons died from AIDS, 4.1 million were newly infected with HIV, and 38.6 million were living with HIV.7 .The first pandemic to be appeared in the second half of 20th century. AIDS is now believed to be a new infection of human being that originated in Central Africa perhaps in the 1950. From there it probably spread to the Caribbean and then to the United States. AIDS is a multi-system disorder of opportunistic infection caused by the human immunodeficiency virus (HIV), which is spread through blood, semen, vaginal secretion and breast milk. The commonest mode of transmission is unprotected sexual intercourse with an HIV- positive partner. Other routes include transfusions of HIV-infected blood and blood products; tissue or organ transplants; use of contaminated needles, syringes, or other skin-piercing equipments; and mother to child transmission during pregnancy, birth or breastfeeding. AIDS is most common among young and middle aged males, and is also encountered more frequently in socio-economically depressed population. . However, AIDS respect no age, sex, and cultural boundaries. Patients with HIV infection are usually clinically asymptomatic during the early course of infection, which may vary in length from months to years. Some patients are diagnosed with HIV infection long before the clinical manifestations appear, while others may not be aware of the infection until full-blown. There are numerous ocular manifestations associated with AIDS, but all may be ascribed to one of four major categories: - Noninfectious associated eye diseases. - Opportunistic ocular infections - Neoplasms. - Neuro-ophthalmic manifestations. The definition of AIDS has been changed a lot over the years. Generally an HIV- infected person is diagnosed with AIDS when his or her immune system is severely compromised and manifestations of HIV infection are 82 | P a g e

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severe. According to Centers of Disease Control (CDC) in USA, AIDS is defined as all persons who are severely immunosuppressed (CD4+ T cell count<200 cells/cu.mm) irrespective of presence of absence of the indicator disease. In general CD4+ T Lymphocyte count has been used to predict the onset of certain ocular infections in patients who are HIV positive.CD4+ T-cell count less than 500 cells/cu mm is associated with Kaposi's sarcoma, HZO, Lymphoma and Tuberculosis.CD4+ T-cell less then 200 is associated with Toxoplasmosis, cryptococcosis, HIV retinopathy and less than 50 is associated with HIV retinopathy, CMV retinitis, Vericella-Zoster retinitis, Mycobacterium avium complex infections. HIV infection has now become a worldwide problem. Around 90% of cases are in developing countries and are unable to afford the expensive medical care required to control the progression of the disease. The current global pandemic of HIV consists of many different regional epidemics in different countries each with its own dynamics and different clinical pattern of evolution .More recently in the Indian subcontinent and southern East Asia the epidemics were late but are accelerating at an alarming rate, so because of absence of any cure the HIV needs changes in people's behavior to stop its spread. In 2007 the total no of HIV patient in the world was 33.2 million and it killed an estimated 2.1 million people including 330, 000 children and in Nepal total HIV infected were around 69000. In the whole world including in Nepal HIV patients are increasing per day. In Nepal the first case was detected in 1988, but the analysis say it is only the tip of the iceberg. 8 HIV has the capability to affect every organ system in the body by direct damage by the virus or by making the host susceptible to opportunistic infections .Ocular manifestations have been reported in upto 70-80% of individuals infected with HIV and it has become apparent that the ocular manifestations almost always reflect systemic disease and may be the first sign of disseminated infections in many cases. Thus Ophthalmologist may be the one to make out sight saving and life prolonging diagnosis. Although treatments for AIDS and HIV can slow the course of the disease, there is currently no vaccine or cure. Antiretroviral treatment reduces both the mortality and the morbidity of HIV infection, but these drugs are expensive and routine access to antiretroviral medication is not available in all countries. Due to the difficulty in treating HIV infection, preventing infection is a key aim in controlling the AIDS epidemic, with health organizations promoting safe sex and needle-exchange programmes in attempts to slow the spread of the virus.

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HIV/AIDS is a non-curable but preventable disease .Development of HAART (Highly Active Anti-retroviral Therapy) has prolonged the life of the HIV infected patients. But a blind patient may not be able to see the world as his well seeing counterpart. So for a better quality of life, a good vision is a must. If ocular problems can be sought earlier by routinely screening programme and regular follow up early and timely medical or surgical intervention could be done for prevention and minimizing potential blinding complications .This could be done by creating awareness regarding all aspects of HIV including sound knowledge about the disease, mode of transmission and high risk behaviors and combined effort of all other specialties which leads to a fruitful and productive life.

Psychology of visual perception

Nabin Paudel B.optom, Final year We are able to enjoy the beauty of the wonderful environment around us, we can see, touch and feel the objects around us, and this is all because we have different sense organs. One of the most important of them is the eye. Eye, as a camera gathers information by the patterns of light from different objects of the environment, this information passes through various pathways (neurons circuits) and finally reaches to the brain where the information is interpreted. This interpretation of what we take in through our senses is called as perception. Brain interprets the information in different ways taking various cues so that the object that we perceive may or may not be the existing real object that we are seeing. Brain interprets the data in one way or the other. This is the reason why we are mistaken in various objects that we see and fall into illusion and interpret the object falsely as they are there which really dont really exist. Various principles regarding human visual perception are explained by different psychologists and few of them are discussed in brief below. You may have seen this famous picture (fig.1) by Danish psychologist which can be interpreted as a white vase on black background or silhouetted profiles on a white background. This is explained by figure and ground principle/processing. Perceptual set operates in such cases and we tend to favor one interpretation over the other. When we identify the figure the contour seems to belong to it and it appears to be in front of the ground. (fig.2) Besides, figure and ground processing, a group of psychologists (gestalt psychologists) have given several universal laws or principles also called as Gestalt principles of visual perception.

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Gestalt means when parts identified individually have different characteristics to the whole (Gestalt- organized whole). For e.g. when we see a tree we are not aware of its different parts but we are aware of the overall object - the tree, though its parts trunk, branches, leaves, fruits are clearly seen. Gestalt principles include: Principle of proximity- figures which are close together are associated, for e.g. see the fig. in the right we not only see the square of dots but also see the rows of dots. Principle of similarity- figures that are similar are associated. It can be demonstrated by the figure in right where we can see alternate columns of circular and square dots as they are equally separated proximity doesnt apply here. Principle of continuity- contours based on smooth continuity are preferred to abrupt change of direction. E.g. in this figure we can see the line a-b and c-d clearly than a-d and c-b. Principle of closure-interpretation which produce closed rather than open figure are perceived. As in this picture there are open as well as closed figures but we perceive closed ones clearly. Principle of smallness smaller areas tend to be seen as figures against a larger background.In this figure we clearly appreciate black cross rather than white cross Principle of surroundness- areas which can be seen as surrounded by others tend to be as figures. In this figure at first we consider black object as figure and white as the background and we cant see actual figure but if we consider the principle of surroundness, in no time we will get the answer. These are few important principles, widely accepted which explain how we perceive the objects around us but sometimes may be forced to give wrong decision though in reality they are not as we perceive. This is not full explanation of visual perception, and there are separate principles for depth perception, motion perception etc as vision is a complex business. Last but not the least lets have a look at some misinterpretations of brain in which we are compelled to give wrong decisions..

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In the first figure is the inner figure exactly circular? Are the two figures in second illusion of same length? Which one of the two monsters do you think is large? Can you say which man near the wall is taller? References: Sensation and perception, E. Bruce Goldstein, Fifth edition Visual perception, Steven Schwartz Vision and visual perception Pshycology, Gleitmann

The Physical effects of Psychological Stress Govinda Ojha Optometrist Tilganga Eye Center A quiet revolution is under way in medical science. Only relatively few years ago, the role of the psyche as a factor in physical disease was almost universally downplayed. Today, however, with the widespread recognition of the importance of the work of Walter Cannon and Hans Selye on the psychic causation of stress and its role in maintaining homeostasis; with the advent and success of holistic medicine as an alternative approach, the recognition of the importance of the mental and spiritual factors in fighting illness has grown into an imperative of medical treatment nearly everywhere in the world. The study of the role of stress in causing and healing disease cause into its own with the work of Cannon and Selye, who carefully studied what happens to the various organs of the body in the presence of stress (which Selye defined clinically as the nonspecific response of the body to any demand made upon it). A number of ailments have since then been identified (and the list gets longer every day) which have known stress related origins. Depending on ones constitution, the non-specific response to stress may affect almost any organ system in the body. Digestive System 86 | P a g e

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Anorexia, nervosa, peptic ulcer, ulcerative colitis, irritable colon, spastic colitis, nervous vomiting & diarrhea. Respiratory System Asthmatic wheezing, bronchial asthma. Cardiovascular System Angina pectoris, coronary insufficiency, essential hypertension, tachycardia, arrhythmias, vascular headache. Endocrine System Hyperthyroidism, diabetes mellitus, menstrual irregularities. Skin Urticaria, warts, neurodermatitis, pruritus, psoriasis. Connective tissue Lupus Erythematosus, Dermatomyositis, Scleroderma Polyarteritis Nodosa. Anxiety Invites infection It was once commonly thought that infectious diseases are only due to infective organisms. Contrary to this common belief a number of observations revealed that colonization of a host by infective organisms does not necessarily result in illness. It is the bodys own level of resistance, which varies with stress, which is the causative factor. Anxiety and other stresses also influence the rate of recovery from such diseases as infectious mononucleosis (Greenfield, 1959) and influenza (Imoden, 1961) as well as the susceptibility to rhinovirus induced common cold ( Totman, 1977) and tularemia (Canter, 1972). Recurrent herpes simplex lesions have been shown to be most frequent in person who tends to feel depressed (Katcher, 1973; Luborsky, 1976). Anger has been known moreover to alter the bacterial composition of the intestine (Holdeman, 1976). From the physiological perspective, psychological stress increases the production of ACTH- releasing factor in the hypothalamus. Therefore, secretion of ACTH (adrenocorticotropic hormone) from the pituitary is raised. ACTH stimulates the adrenal cortex to increase the level of corticosteroids. The increased blood concentration of corticosteroids & other steroid hormones in turn depresses the immunological defense mechanism, which increases the bodys susceptibility to infective organisms. Epinephrine & nor-epinephrine (which are catecholamine hormones secreted by adrenal medulla) are regularly increased in response to stressful conditions (Frankenhaeser, 1971). Both have been found to decrease various immune responses including anaphylaxis (Schmutzler and Freundt, 1975) and delayed cutaneous hypersensitivity (Kram, 1975). The evidence also suggests that may suppress the immune function (Croe, 1969). Stressful life experiences have also been found to induce elevation in free fatty acid (Froberg, 1971) and cholesterol (Kasl, 1968) levels, both of which have immunosuppressive effects (Dilman, 1977).

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Psychological Stress - Slow poison When one becomes emotionally disturbed, why is organic illness not seen immediately? This is a very good question. In fact, our body has a large amount of reserve capacity. For example, our heart possesses 4 to 6 times more capacity than minimum required. Thus only when the capacity of the heart is reduced 4 to 6 times below normal do we suffer heart failure. Likewise, a good surgeon can remove 12 feet of small intestine out of the 22 feet without harming digestion. In the same way, he can remove one kidney without reducing the normal performance. Our bone marrow can increase the production of red blood cells almost seven folds whenever required. The fact is, then, every emotional disturbance does cause organic changes and reduces the attacked organs reserve capacity. But only when all of our organic reserve is depleted we do suffer from overt organic diseases (clinical cases). The process of depletion of reserve capacity may take many years before clinical cases are seen. In this way, psychological stress acts as a slow poison. In nut shell, psychological stress has harmful effects on physical and mental health. Stress reduces memory power, intellectual efficiency and even brings premature old ages. Stress in long run invites organic diseases. Hence, if only we can keep away stress and learn to remain calm & peaceful we can not only prevent ourselves from various illnesses but also aid in healing ailments.

Solar Eclipse and Ocular Health Hazards

Rabindra Adhikary B. Optom, 8th Batch Sighting of the solar eclipse is a well-established clinical entity of macular damage, a self-induced cause of blindness. Accounts of solar damage to the eye existed for centuries. After observing burns of the retina caused 88 | P a g e

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by watching an eclipse, Socrates warned against the danger of viewing the sun during an eclipse and suggested instead viewing its reflection in water. Galileo reportedly was injured by using a telescope for solar eclipse observation. In many societies where there are sun worshippers, eye injury is a well-documented phenomenon recognized after ritual sun observation. The first description of visual damage caused by sun was given by the Swiss physician Bonetus, during the 17th century. Clinical cases of eclipse blindness were subsequently reported by Saint-Yves in 1722. Cases of solar retinopathy reported in the literature since the 18th century was basically the result of viewing solar eclipse. The term eclipse retinopathy is frequently employed when the condition is sustained as a result of viewing a solar eclipse. The vast majority of solar retinal injuries occur as a result of viewing a solar eclipse without adequate protection. The extent of structural retinal damage and associated visual impairment is dependent upon the intensity and duration of solar exposure. The exact mechanisms, which operate to produce solar retinal compromise, are not completely known, but are believed to involve a thermally enhanced photochemical process. There can be at least five separate types of hazards to the eye and skin from solar eclipse: a. Ultraviolet photochemical injury to the skin (erythema and carcinogenic effects), and to the cornea (photokeratitis) and lens (cataract) of the eye (180 nm to 400 nm). b. Thermal injury to the retina of the eye (400 nm to 1400 nm) c. Blue-light photochemical injury to the retina of the eye (principally 400 nm to 550 nm; unless aphakic, 310 to 550 nm)2 d. Near-infrared thermal hazards to the lens (approximately 800 nm to 3000 nm). e. Thermal injury (burns) of the skin (approximately 400 nm to l mm) and of the cornea of the eye (approximately 1400 nm to 1 mm). The Sun can be viewed safely with the naked eye only during the few brief seconds or minutes of a total solar eclipse. Partial eclipses, annular eclipses, and the partial phases of total eclipses are never safe to watch without taking special precautions. Even when 99% of the Sun's surface is obscured during the partial phases of a total eclipse, the remaining photospheric crescent is intensely bright and cannot be viewed safely without eye protection. Severe burn of the cornea and face can occur with prolonged exposure to ultra violet light. Ultra violet light being at the shorter end of the spectrum cannot penetrate the cornea. Maximum damage is to the corneal epithelium. The epithelium peels off causing severe pain but re-epithelializes. The spectrum of the light source is an important factor in retinal injury and the wavelengths in the near-UV (320 to 400nm) and short 89 | P a g e

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wavelength (400 to 500nm) light ranges are primarily responsible for the phototoxic lesion. Clinically, the lesion usually is not detected until 24 to 48 hours after the initial exposure and this includes central scotoma, metamorphopsia and photokeratitis. Severe loss occurs after 1 2 days and visual acuity may be reduced to 6/60 but has been noted to return to 6/12 or better within 4 to 6 months. Since a natural phenomenon such as solar eclipse is predictable, public education is the only preventive measure. According to a two-month long (March 29th 2006 to 29th May 2006) study conducted at Komfo Anokye Teaching Hospital in Kumasi in Central Ghana following the eclipse of the sun by the moon on March 29th 2006, ocular health hazards induced due to improper viewing of the eclipse can be significantly curtailed by the extensive mass public education on the proper way to view the phenomena. Kallmar and Ygge cited that 15 patients all of whom viewed the solar eclipse in Sweden for one year and reported that Photo induced foveal injury gave rise to subjective visual disturbances, reduced VA and morphological changes in the fovea. Central Scotomas could still be seen in all patients one year after their foveal injury when scanning laser ophthalmoscopy was used. Similar finding was reported in the Strasbourg study when the multifocal electroretinogram (ERG) was used on 4 patients after the 11th August 1999 eclipse of the sun. Definitely, the use of scanning ophthalmoscopy and multifocal electroretinogram offer the best possibility of detailed examination of small retinal lesions and foveolar deficit which can sometimes be difficult to localize with ophthalmoscopy. Most literatures suggest solar eclipses should not be watched. However, if one needs to watch it, use special eclipse viewers or exposed camera film or special protective filters (Eclipse Shades, Eclipse Shade Plus, Sun Spotters, Solar Viewing Glasses, Eclipse Safety, Aluminized Polyester). If not the maculae, would be burnt by the sun. Lasting visual damage can follow a solar retinal burn with little or no form of viewing devices. While it is reasonable to surmise that some patients may ignore their visual complaints and not report to the hospital, we can conclude that prevention remains the best treatment and there is a need to educate the public in this regard not only against the damages of retinopathy but also other negative health hazards of the eclipse. Why Dangerous? 1. Much accepted concept: As we view when there is total eclipse, our eye is dilated and at some point when only a portion of sun will be visible flooding of harmful light rays into dilated pupil will occur and so the effect is more pronounced than in normal days when our eye would be missed. 2. When moon and earth are linearly aligned, the resultant additive gravity of both of them will attract more of the divergent detrimental rays (emerging from the sun) from the outer space, and hence the effect is more pronounced in the earth (moon as well but it is without lives) 90 | P a g e

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How to watch it, then? The safest and most inexpensive method is by projection, in which a pinhole or small opening is used to cast the image of the Sun on a screen placed a half-meter or more beyond the opening. Projected images of the Sun may even be seen on the ground in the small openings created by interlacing fingers, or in the dappled sunlight beneath a leafy tree. Binoculars can also be used to project a magnified image of the Sun on a white card, but you must avoid the temptation of using these instruments for direct viewing. The Sun can be viewed directly only when using filters specifically designed for this purpose. Such filters usually have a thin layer of aluminum, chromium or silver deposited on their surfaces that attenuates ultraviolet, visible, and infrared energy. One of the most widely available filters for safe solar viewing is a number 14 welder's glass, available through welding supply outlets. More recently, aluminized mylar has become a popular, inexpensive alternative. Mylar can easily be cut with scissors and adapted to any kind of box or viewing device. No filter is safe to use with any optical device (i.e. telescope, binoculars, etc.) unless it has been specifically designed for that purpose. Unsafe filters include color film, some non-silver black and white film, medical x-ray films with images on them, smoked glass, photographic neutral density filters and polarizing filters. References: 1. International Lighting in Controlled Environments Workshop 2. D.H Sinley, 1994 NASA-CP-95-3309 3. Progress in Lens and Cataract Research.Dev Ophthalmol. Basel, Karger, 2002, vol a. 35, pp 104-112 Fred Espenak Adapted from NASA RP 1383 Total Solar Eclipse of 1998 February 26, April 1996, p. 17. Ophthalmic and Physiological Optics Vol 21, no. 6, 427-429, 2007 Community Eye Health J 2005; 18(55): 106-108 Trans Am Ophthalmol Soc. 1987; 85:120-158 African J of Health Sciences, Vol. 14, Num.3-4, 2007, pp 160-163

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