The Sight 200 8

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NOSS 07/08: At a glanceNepal 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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The Sight 200 8 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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The Sight 200 8 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 Sight 200 8THE 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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The Sight 200 8When 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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The Sight 200 82.

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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The Sight 200 8Not 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

The Sight 200 8PSYCHOLOGICAL 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

The Sight 200 8strategies 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. REFERENCES1. 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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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

The Sight 200 8compound 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

The Sight 200 8yet 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 SolutionPrakash 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

The Sight 200 8has 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

The Sight 200 8The 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 careDr. 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

The Sight 200 8A 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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The Sight 200 8sports-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

The Sight 200 8Optometrist, 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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The Sight 200 8

Infectious Keratitis a clinical distinctionDr 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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The Sight 200 8All 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

The Sight 200 8the 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

The Sight 200 8Classically, 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

The Sight 200 8the 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 NystagmusJyoti 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

The Sight 200 8occurs 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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The Sight 200 8 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

The Sight 200 8 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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The Sight 200 8temporarily 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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The Sight 200 8Besides 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

The Sight 200 8about 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

The Sight 200 8o 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

The Sight 200 8The 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

The Sight 200 8proving 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 ManagementDr. Sanjeev Bhattarai M.Optom.,O.D.38 | P a g e

The Sight 200 8Pediatric 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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The Sight 200 8Other 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 stepsHistory: 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 Sight 200 8

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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The Sight 200 8symptoms 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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The Sight 200 8

Glaucoma Diagnostic Tools: HRT and GDxMahesh 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

The Sight 200 8HRT: 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

The Sight 200 8Access 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

The Sight 200 8and 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

The Sight 200 88. 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

The Sight 200 8Rehabilitation 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

The Sight 200 8of 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 report49 | P a g e

The Sight 200 8Nabin Raj Joshi