Compassion

Contents EditorialStimulus Lasik is increasingly becoming popular especiallyClinical among younger generations who want to be free of spectacles. But very few understand that a person has - Orbscan to meet many clinical criteria for undergoing this - Endophthalmitis Kit surgery. Orbscan is a very special test that helps the - Aphakia ophthalmologists determine if the patient is fit for - Vernal Keratoconjunctivitis lasik. It is the only test that can reveal the shape of the - Lid Tumour posterior surface of cornea. The article given here will take you to the details of this diagnostic test.Non-clinical Aravind’s manufacturing wing, Aurolab has created a lasting impact in the field of ophthalmic consumables - Balanced Salt Solution by developing products at affordable costs especially for the developing countries. Here the readers areIt Happened to Me introduced to E-Kit that helps in providing on-time treatment with reduced inventory cost. - How corneal transplantation changed the Of the five main types of ocular allergy, vernal kerato course of life conjunctivitis is a chronic, bilateral, and severe form of allergic inflammation affecting the ocular surface.Quiz This can cause severe damage to the ocular surface, leading to corneal scarring and vision loss if not - Quiz treated properly. The article given here provides you firsthand information about this disease.How to Use Me The very mention of the word cancer itself creates a sense of fear among the public. Now a days it has - Hand-held Autorefractometer become extremely common and can affect any part of the body. Here we discuss cancer of the eye lids, skin ofInspiration which is the thinnest and most sensitive on our body. ‘‘How to use me’’ section introduces you to hand-held - Chain of Love auto refractometer, its uses and special features. All the other regular columns feature in this issue.Moral Story We wish you all an informative reading. - The 8 Monkeys Compassion July - September, 2014Situational Analysis - Consanguineous marriage and its impact on childrenEditorial TeamDr.Usha KimMs. AnujaPrinted at Leo Prints, Madurai

1Do not believe in anything simply becauseyou have heard it. Do not believe in anythingsimply because it is spoken and rumouredby many. Do not believe in anything simplybecause it is found written in your religiousbooks. Do not believe in anything merely onthe authority of your teachers and elders. Donot believe in traditions because they havebeen handed down for many generations.But after observation and analysis, when youfind that anything agrees with reason and isconducive to the good and benefit of one andall, then accept it and live up to it. - Buddha Compassion July - Sep, 2014

2 ClinicalOrbscanIntroduction annular arc in the video image. The outer and inner edges of this respectively correspondOrbscan is a sophisticated ocular diagnostic to the anterior and posterior surface ofsystem which utilises the latest technology the illuminated corneal volume. Resultand computer analysis. It is a quick and of this process, which is called the directpainless diagnostic test that analyses and triangulation is an anterior corneal surfacemeasures the corneal shape, curvature and point located in x,y,z space.thickness. The light rays are projected over thecornea in a pattern and the reflection of the Raytrace triangulationsame is evaluated. This ultimately determinesa patient's eligibility for LASIK. It also assists Raytrace is an undistorted measurement ofthe surgeon in analysing the steepness of an internal ocular surface capable of detectingcornea and any irregularrities that may exist. and analysing posterior corneal abnormalties, where corneal anomalies first appear.Optics of Orbscan Customisable quad maps show anyThe Orbscan utilises a unique slit scanning combination of measurements in onecorneal and anterior segment topography convenient format.system that stimultaneously measures bothsurfaces of the cornea. Orbscan acquiresover 9000 data points in 1.5 seconds tometiculously map the entire corneal surfaceand analyses the curvature measurements onboth the anterior and posterior surfaces of thecornea.Diffuse ReflectionA slit beam intercepts an optically smoothsurface and the beam splits into a specularreflected beam and a refracted beam. Volumescattering is similar to surface diffusereflection, where the light is scattered omnidirectionally.Defect triangulationA planar slit beam diffusely reflected fromthe convex shell of the cornea, appears as anTopography - study of surface shape and feature; Specular reflection - mirror like reflection; Omni direction - every direction;Sophisticated - highly developed; Meticulous - carefullyARAVIND EYE CARE SYSTEM

Pre requisites for orbscan 3• Clear cornea SRI - Surface regulatory Index• Good tear film• Good focus - It is the measure of local fluctuations in• Good fixation central corneal powerUses of Orbscan - Correlates to potential visual acuity - High SRI is seen in dry eyes, contact lensa. Screening tool for refractive surgeries wearers and keratoplasty patientsOrbscan is used to screen patients forrefractive surgery. Various maps help in SAI - Surface assymetry indexevaluating the anterior float, posteriorcurvature, pachymetry and keratometry to - Diffrence in corneal powers at everydecide fitness for refractive surgery. ring (180 degrees) over the entire corneal surfaces.b. To diagnose Keratoconus - High in keratoconus,post keratoplasty.Orbscan has an important role in diagnosing decentered refractive procedure,traumakeratoconus and monitoring the progression and warpage.of keratoconus. - Good spectacle correction is not achievedc. To aid in contact lens fitting for high SAI. - Sr. JeyechandraOrbscan helps in contact lens fitting by giving Cornea Clinic, Aravind - Maduraithe base curve, white to white diameter andanterior curvature.d. To aid in suture removal for keratoplastypatientsHelps to identify the axis of tighter suture andthus aid in planning suture removal in postkeratoplasty patients.e. To aid in Implantable Contact LensImplantationHelps in measuring white to white diameterof cornea and anterior chamber depthprecisely which is of utmost importance inimplantable contact lens.Pachymetry - measuring the thickness of the cornea; Keratoconus - cornea bulges into a cone like shape; base curve - curvatureof the back surface; Keratoplasty - surgery of cornea; Precisely - accurately; Warpage - change in the shape of corneal surface Compassion July - Sep, 2014

4 ClinicalEndophthalmitis KitEmergency Kit (E-kit) contains the most 2. Povidone Iodine 5% solution for asepticessential devices, antibacterial and antifungal preparation of the eye.antibiotics for initial emergency treatmentof bacterial and fungal endophthalmitis. It is 3. Wire speculum to open the eye.a collection of consumables that are neededfor the treatment of endophthalmitis. It has 4. Winged infusion set of 27 g for vitreousthe drugs in quantities such that it is a single biopsy.stop solution before use. All these factorsadd up to offer a significant advantage to 5. 10-mL syringes with 20-g needlesophthalmologists, especially those in remoteareas. 6. Sterile water for injection and to prepare the drug in the original vial.Contents of E-Kit 7. Tuberculin syringes for final drug loading.1. Sterile swab sticks to clean and prepare the eye. 8. 30-g needles for final intravitreal injections. Comparison of Antibiotic PreparationAntibiotic Traditional E-KitVancomycin Add 10 ml of water to a Add 10 ml of water to a 500-mg vial Withdraw 0.2 ml. 100-mg vial. Add 0.8 ml of water. Keep 0.1 ml (1.0 mg of Keep 0.1 ml (1.0 mg of vancomycin) vancomycin)Ceftazidime Add 2.2 ml of water to a Add 10 ml of water to a 500-mg vial withdraw 0.1 ml 250-mg vial. Add 0.9 ml of water. Keep 0.1 ml (2.5 mg of ceftazidime) Keep 0.1 ml (2.25 mg of ceftazidime)Voriconazole Add 20 ml of water to 200 mg vial Add 1 ml of water to a 1-mg vial. Withdraw 0.1 ml. Keep 0.1 ml (100 mg) Add 0.9 ml of water. Keep 0.1 ml (100 mg)Endophthalmitis - inflammation of the internal coats of the eye; Intravitreal - infection into the vitreous; Speculum - tool forexaming body cavities; Biopsy - sampling of cells or tissues; Remote - farawayARAVIND EYE CARE SYSTEM

5Advantages (b) nonavailability of recommended antibiotics, and (c) inexperience in• The easy-to-prepare antibiotics preparing the antibiotics. includes vancomycin, ceftazidime, and voriconazole. Conclusion• The E-Kit is intended to overcome The E-Kit benefits include accurate and three important hurdles in instituting easy preparation of antibiotics, safe vitreous prompt therapy in bacterial and fungal biopsy and intravitreal injection, and reduced endophthalmitis; they include (a) lack of ordering time and inventory cost. an appropriate device for vitreous biopsy, - Sr. Ramalakshmi Tutor, Operation Theatre, Aravind - TirunelveliOvercome - succeed in dealing with; Hurdle - problem Compassion July - Sep, 2014

6 ClinicalAphakiaDefinition • Erythropsia and cyanopsia - due to entry of infrared and ultraviolet rays in theAphakia is the absence of the crystalline absence of the crystalline lens.lens in the eyeball. Mainly it is due tosurgical removal, a perforating wound, Signs : (Anterior to posterior)ulcer or congential anomaly. It causes lossof accommodation and far sightedness • Limbal scar in case of surgical aphakia(hyperopia). Complications include • Deep anterior chamberdetachment of the vitreous or retina and • Iridodonesis - Tremulousness of the irisglaucoma. due to loss of support of lensCause of Aphakia • Jet black pupil • Loss of 3rd and 4th purkinje images.1. Congenital • Fundus examination reveals a small2. Surgical - removal of lens as in cataract hypermetropic fundus extraction. • Retinoscopy shows high hypermetropia3. Aphakia due to absorption of lens - Treatment sometimes seen in children after trauma.4. Traumatic extraction of crystalline lens. 1. Spectacles5. Posterior dislocation of lens into the • It should be prescribed with about + 10 D vitreous causes optical aphakia. lens for correction of aphakia.Optics in Aphakia • It should also include correction for surgical astigmatism and +3 D to +4 D for• The lens is important in refraction and near vision. hence its removal results in considerable decrease in the refractory power of the • Now a days spectacles are not preffered eye. for use in aphakia due to many disadvanges.• The eye becomes highly hypermetropic.• The power of eye decreases from +60D to Advantages of using spectacles in Aphakia: +44D. • Cheap• The power of accommodation is lost. • Easy to use• The posterior focal point lies behind the • No complications eye ball. DisadvantagesClinical features • The images are magnified - above 30% - hence not useful in unilateral aphakia as itSymptoms causes diplopia.• Defective vision due to high hypermetro- pia and loss of accommodation.ARAVIND EYE CARE SYSTEM

• The field of vision is decreased 7 considerably. • Freedom from handling of the optical• Spherical and chromatic aberration of devices (eg. contact lens or heavy high power lenses. spectacles).• Ronne ring scotoma (Jack in the box • Cosmetically, it is best accepted. phenomenon). Disadvantages• Prismatic effect of the thick lenses.• High power is cosmetically not acceptable. • Risks and complications may be more (eg. corneal decompensation, lens2. Contact lenses displacement, chronic iridocyclitis, posterior capsular opacification, etc)Advantages over spectacles • It needs specially trained surgeons and• Produce less magnification (7 to 8%). sophisticated instruments like operative• Better field of vision. microscope.• Less chromatic and spherical abberation.• No prismatic effect. • Initially, the cost involved is more.• Cosmetically more acceptable. An IOL implantation may be done in anDisadvantages aphakic eye after careful examination. This may be:• Costly • Secondary anterior chamber IOL (AC IOL)• More care is required while using contact in aphakia following ICCE. lenses - may not be suitable for young children and elderly. • Secondary posterior chamber IOL• Complications related to use of contact (PC IOL) - in aphakia following ICCE. lenses. • Secondary scleral fixation IOL (SFIOL) - in3. Intraocular lens implantation aphakic following ICCE.Advantages 4. Refractive surgery : (This is the newly emerging treatment for aphakia)• This is the preferred method nowadays• The lens can be implanted in the capsular • Keratophakia : A lenticule prepared from the donor cornea is placed with in the bag. lamellar of the patient's cornea.• Image magnification is only 0-1%.• No spherical and prismatic aberrations. • Epikeratophokia : A lenticule prepared• Minimal or no aniseikonia, with rapid from the cornea is stitched to the patients cornea after removing the epithelium. return binocularity.• Normal peripheral field of vision and • Hyperopic LASIK : The peripheral part of cornea is ablated with excimer laser eccentric vision. flattening the peripheral cornea and• Good hand-eye co-ordination and spatial steepening the central cornea and this corrects hypermetropia. sensation. - Ms. Banu Priya Refraction. Aravind - MaduraiHypermetropia - farsighted; Tremulousness - trembling; Purkinje image - reflection of structure of the eye; Diplopia - doublevision; Congenital - present from birth; Iridocyclitis - inflammation of the iris and vitreous cavity Compassion July - Sep, 2014

8 ClinicalVernal KeratoconjunctivitisIntroduction 2. Limbal diseaseAllergic conjunctivitis is a Type I (immedi- Typically affects black and aAsian patients.ate) hypersensitivity reaction, mediated by 3. Mixed VKCdegranulation of mast cells in response to Mixed VKC has features of both palpebral and limbal disease.the action of IgE. Diagnosis There is evidence of an element of Type IVhypersensitivity in atleast some forms. The diagnosis is clinical and investigations are generally not indicated. Vernal keratoconjunctivitis (VKC) is arecurrent bilateral disorder in which both IgE Symptoms- and cell mediated immune mechanisms playimportant roles. • Intense itching • May be associated with lacrimationPathogenesis • Photophobia • Foreign body sensationIt primarily affects boys and onset is generally • Burning sensation and thick mucoidfrom the age of 5 years onwards (averageage is 7 years). Ninety five percent of cases discharge.go in to remission by the late teens although • Increased blinking is commonmany of the remaining develop atopickeratoconjunctivits. VKC is rare in temperate Palpebral diseaseregions, but relatively common in dryclimates. 1. Early mild disease is characterized by conjunctival hyperemia and diffuse VKC often occurs on a seasonal basis, witha peak incidence over late spring and summer,although there may be mild perennialsymptoms.Classification1. Palpebral VKCPalpebral VKC primary involves the uppertarsal conjunctiva. It may be associated withsignificant corneal disease as a result ofthe close apposition between the inflamedconjunctiva and the corneal epithelium.Degrannulation -cell break down; Mast cells - cells causing allergy; IgE - immunoglobulin - E; Hyperemia - increase of blood flow;Papillary hypertrophy - inflammation of the tarsal conjunctiva; Cobblestone - a naturally rounded stoneARAVIND EYE CARE SYSTEM

papillary hypertrophy on the superior 9 tarsus. from inflammatory mediators and direct2. Macropapillae (<1mm) have a flat - mechanical effect from papillae. topped polygonal appearance reminiscent of cobblestones. 3. Plaques : Plaques and shield ulcers may develop in palpebral or mixed disease3. Progression to giant papillae (>1mm) when the exposed Bowman membrane can occur, as adjacent smaller lesions becomes coated with mucus and calcium amalgamate. phosphate, leading to inadequate wetting and delayed re-epithelization. This4. Mucus deposition between giant papillae. developement is serious and warrants urgent attention to prevent secondary5. Decreased disease activity is characterized bacterial infection. by milder conjunctival injection and decreased mucus production. 4. Subepithelial scars that are typically grey and may affect vision.Limbal disease Other manifestations1. Gelatinous limbal conjunctiva papillae that may be associated with transient • Vascularization does not tend to be apically - located white coloured cellular prominent, though some peripheral collections. superficial vessel ingrowth is common especially superiorly.2. In tropical regions limbal disease may be very severe. • Keratoconus and other forms of corneal ectasia are more common in VKC.Keratopathy • Herpes simplex keratitis is more commonIs more frequent in palpebral disease and may than average, though less than in Atopic.take the following forms. Keratoconjunctivitis (AKC). It can be1. Superior punctate epithelial erosions aggressive and is occasionally bilateral. associated with sheets of mucus on the • Eyelid disease is usually mild, in contrast superior cornea. to AKC.2. Epithelial macro erosions: It is caused - Ms. S.Vadakkuvaselvi by a combination of epithelial toxicity Cornea - OPD, Aravind - SalemMediator - chemicals released in response to injury; Atopic keratoconjunctivitis - allergic conjunctivitis; Corneal ectasia -secondary keratoconus; Aggressive - severe Compassion July - Sep, 2014

10 ClinicalLid TumourAny abnormal growth in eyelids constitutes embryonic lines of closure. It is similar ineyelid tumours. They can be benign or appearance to an epidermal inclusion cyst.malignant in nature. All eyelid lesionsshould be evaluated to rule out malignancy. 4. Dermoid cyst: It is usually subcutaneousMalignant lid tumours can present with or deeper and is typically attached to theulceration, bleeding, irregular shape, irregular periosteum at the lateral end of the brow.margin, abnormal colour, lack of pain and loss It is caused by skin sequestered duringof eyelid margin. If malignancy is suspected embryonic development.biopsy should be performed to confirmdiagnosis. The tumours can be benign and 5. Sebaceous cyst: It is caused by a blockedmalignant. pilosebaceous follicle and contains sebaceous secretions. It is only rarelyI. Benign nodules and cyst: found on the eyelid although it may occasionally occur at the inner canthus.1. Chalazion: A chalazion (meibomian cyst) is a chronic, sterile, granulomatous 6. Cyst of Zeis: It is a small, non-translucent inflammatory lesion caused by retained cyst on the anterior lid margin arising sebaceous secretion leaking from the from obstructed sebaceous glands meibomian or other sebaceous glands into associated with the eyelash follicle. adjacent stroma. A chalazion secondarily infected is referred to as an internal 7. Cyst of Moll: It is a small retention cyst of hordeolum. Presentation is at any age the lid margin apocrine glands. It appears with a gradually enlarging painless as a round, non-tender, translucent fluid- nodule. Very occasionally a large upper lid filled lesion on the anterior lid margin that chalazion may press on the cornea, induce may have a bluish tinge. astigmatism and cause blurred vision. Surgery done is incision and curettage. II. Benign epidermal tumours The eyelid is everted with a special clamp, the chalazion is incised vertically and its 1. Squamous cell papilloma: A squamous contents curetted through the tarsal plate. cell papilloma (fibroepithelial polyp) is a very common condition that has a2. Epidermal inclusion cyst: It is usually variable clinical appearance but common caused by implantation of epidermis into histological features. It presents as a flesh- the dermis following trauma or surgery. It coloured, narrow based pedunculated is a slow-growing, round, firm, superficial lesion or a broad-based (sessile) lesion or subcutaneous lesion containing keratin. which may exhibit a raspberry-like surface. Treatment involves simple3. Epidermoid cyst: It is uncommon and excision. usually developmental, occurring along 2. Basal cell papilloma: Basal cell papilloma (seborrhoeic keratosis, seborrhoeic wart)Chalazion - bump on the eyelid; Blepharoconjunctivitis - conjunctivitis with inlammation of the eyelid; Malignant - harmfulARAVIND EYE CARE SYSTEM

is a common, slow-growing condition 11 found on the face of elderly individuals. It presents as a discrete, greasy, brown 2. Sebaceous cell / Meibomian gland carcinoma: plaque with a friable verrucous surface and a ‘stuck on’ appearance. Treatment Most common eyelid involves shave excision of flat lesions and tumour in India. It can excision of pedunculated lesions. present as nodule with yellow colour. It can be3. Melanocytic nevus: Large lesions have mistaken for a chalazion potential for malignant transformation (recurrent) or chronic of up to 15%. It presents usually as small blepharoconjunctivitis. lesion with uniform colour. A kissing or The presence of yellowish material in tumour split nevus is a rare type of congenital is characteristic of sebaceous cell carcinoma. nevus that involves the upper and lower Treatment includes wide margin surgical eyelid and may occasionally contain excision with tumour free margins in frozen numerous hairs. Treatment, if necessary, section. involves complete surgical excision. 3. Squamous cell carcinoma:III. Malignant eyelid tumours: Most common Usually occurs ineyelid tumours are: old age. Chronic sunlight exposure is• Basal cell carcinoma a risk factor. It can present as nodule,• Sebaceous cell/meibomian gland plaque or ulcerative carcinoma lesion which can easily bleed. Sometimes it can spread to lymph nodes. Treatment is total• Squamous cell carcinoma surgical excision with tumour free margins in frozen section. Sometimes radiotherapy may• Malignant melanoma be required.1. Basal cell carcinoma: 4. Malignant melanoma:Most common It is a rare lid tumour.malignant tumour of It can arise fromeyelid. It is usually pre-existing nevus.seen in old age. It It presents as flat orcommonly involves elevated pigmentedlower lid and medial lesion with irregularcanthus. It can border. It maypresent as nodule with central ulceration. ulcerate and bleed. Treatment is total surgicalIt spreads and destroys surrounding tissue excision with tumour free margins in frozenlike a rodent (rat), so it is also called rodent section.ulcer. Treatment is total surgical excision with3mm surrounding normal skin with tumour - Ms. R. Sundarifree margins in frozen section. Sometimes Orbit -OT Supervisor, Aravind - Madurairadiotherapy may be required.Benign - not harmful; Excision - removal; Lesion - wound; Nevus - a birthmark in the form of a raised red patch. Compassion July - Sep, 2014

12 Non -ClinicalBalanced Salt SolutionSolution sodium hydroxide and/or hydrochloric acid (to adjust PH), and water for injection. TheA balanced salt solution (BSS) is a solution PH is approximately 7.5. The osmolality ismade to a physiological PH and salt approximately 300 mOsm/Kg.concentration. Solutions include sodium,potassium, calcium, magnesium, and chlorine. BSS+Balanced salt solutions are used for washingtissues and cells and are usually combined This solution contains dextrose, glutathionewith other agents to treat the tissues and and bicarbonate apart from other normalcells. They provide the cells with water constituents of BSS. This has shown to beand inorganic ions, while maintaining a effective in patients with diabetes undergoingphysiological PH and osmotic pressure. vitrectomy. There have been some reports of corneal edema post-operative in patientsBSS® Sterile Irrigating Solution in whom BSS plus was used. It comes in 2 parts – part 1 has sterile irrigating solution;This is a sterile balanced salt solution, each part 2 contains BSS plus concentrate with a 20ml containing sodium chloride (NaCl) ml syringe. Both the parts need to be mixed0.64%, potassium chloride (K Cl) 0.075%, before ophthalmic surgery.calcium chloride dihydrate (CaCl2•2H2O)0.048%, magnesium chloride hexahydrate Clinical Pharmacology(MgCl2•6H2O) 0.03%, sodium acetatetrihydrate (C2H3NaO2•3H2O) 0.39%, sodium BSS Sterile Irrigating Solution is an isotoniccitrate dihydrate (C6H5Na3O7•2H2O) 0.17%, solution for irrigating tissues of the eyes. Indications and usage For use as an extra ocular and intraocular irrigating solution during ocular surgical procedure involving perfusion of the eye with an expected maximum duration of less than 60 minutes. Warnings • Not for injection or intravenous infusion. • Do not use unless product is clear, seal is intact and container is undamaged. • Do not use if product is discolored or contains a precipitate.Precipitate - a substance deposited in solid form from a solution ARAVIND EYE CARE SYSTEM

• Single patient use only. The contents of 13 this bottle should not be used for more than one patient. aqueous fluids should be used with caution in diabetes patients undergoing vitrectomy• The use of additives with this solution since intraoperative lens changes have been may cause corneal decompensation. observed.• This solution contains no preservative, There have been reports of corneal unused contents should be discarded clouding or edema following ocular surgery in which BSS Sterile irrigating solution wasPrecautions used.Open under aseptic conditions only. Prior to Adverse Reactionsuse, check the following: tip should be firmlyin place, irrigating needle should be properly Irritation or any other trauma to the cornealseated; squeeze out several drops before endothelium may result in corneal swellinginserting into anterior chamber. The needle or bullous keratopathy. Postoperativeshould be removed from the anterior chamber inflammatory reactions as well as incidents ofprior to releasing pressure to prevent suction. corneal edema and corneal decompensationStudies suggest that intraocular irrigating can occur.solutions which are iso-osmotic with normal - Sr.Krishnammal, Sr.Ramalakshmi, Operation Theatre, Aravind - Tirunelveli.Additive- a substance added to something in small quantities to improve or preserve it Compassion July - Sep, 2014

14Herewith we present some ophthalmic terminologies and their simple definitions which maybe of extreme use for you in your daily work. This series will be continued in the alphabeticalorder in the upcoming issues.-A- AtrophyAqueous flare Loss of cells and tissue.The characteristic appearance of a beam -B-of slit-lamp light when shone through theanterior chamber. It signifies an excess of Band keratopathycells and protein in the aqueous fluid. Forexample in anterior uveitis. Deposition of calcium in the cornea associated with degenerative cornealAqueous humour / fluid disease, high blood calcium levels and juvenile arthritis.The clear fluid which fills the anteriorand posterior chambers of the eye. These Bells palsychambers are both in the front part of theeye. (Note the vitreous cavity fills the body Weakness of the nerve that supplies theof the eye). muscles of facial expression on one half of the face (right or left).Argyll-Robertson Pupil Bells phenomenonCharacteristic finding of loss of pupillarylight reflex and preservation of the The normal outward and upward movementaccommodative reflex to light, associated of the eyes on forceful closure of the eyelidswith tertiary syphilis. or during sleep.Astigmatism BlepharitisInstead of the front surface of the eye being Inflammation of the eyelids.round it is more oblong. This preventsthe light being focused in the right way Blepharoplastyand leads to blurring. Astigmatism can besecondary to the shape of the cornea or the Plastic surgery of the eyelids.lens and is usually correctable with spectacleor contact lenses. BlepharospasmAsteroid hyalosis Involuntary spastic closure of the eyelids.A condition in which there are asymptomatic Branch retinal artery/vein occlusionopacities in an otherwise normal vitreous,composed of calcium and lipids. Occlusion of one of the branches of the central artery/vein which supply the retinaAsthenopia / 'eye strain' leading to a field defect which if small and peripheral may go unnoticed by the person.Ocular discomfort arising from use of theeyes. Buphthalmos Large eyeball in infants associated with congenital glaucoma. ARAVIND EYE CARE SYSTEM

How corneal transplantation changed 15the course of life It happened to meThe couple, Suresh and Malathy (name changed) had three children. Theirs was a poor family.Vanitha was their first child. She developed ulcer in her left eye when she was in 12th standard.She was taken to a nearby ophthalmologist where she underwent surgery. Even then her visioncould not be saved. Later her right eye was also affected with the same problem. Malathy wasextremely worried thinking of her daughter’s future. It was then their neighbours suggested herto take Vanitha to Aravind Eye Hospital. Malathy brought Vanitha to Aravind – Madurai. After examining her, the ophthalmologistsuggested corneal transplantation. Malathy was very much concerned about the surgery as shethought her daughter’s right eye too might lose vision. They were given detailed counseling. Itwas then Malathy revealed that they were not in a position to afford this surgery. The counsellorsgave her hope that they would make provisions for free surgery and assured her that all possiblethings would be done to save her vision. Surgery was performed Vanitha's vision was improved to the extent that she started seeingthings clearly. “We never expected that the vision would be improved to this level. We areextremely happy now”, said Malathy and Vanitha. The doctors also suggested a prosthesis for herleft eye. Vanitha had stopped schooling since she lost vision in her left eye. Now after regainingvision in her right eye, she resumed her studies. She promised that she would do her maximumto help others gain vision. - Source: S.A Vellaiammal Cornea Clinic, Aravind - Madurai Compassion July - Sep, 2014

16Quiz Quiz1. What are the risks of cataract surgery?2. What is after-cataract?3. How is after-cataract treated ?4. What is radiation cataract?5. What is secondary cataract?6. Why do patients wear spectacles after cataract surgery?7. What is the advantage of ReSTOR IOL?8. What are the disadvantages of multifocal implants?9. What type of medicines should be stopped before cataract surgery?10. Under which conditions a cataract should be removed even if it does not cause problems with vision?11. What does the tiny leak in blood vessels in the eye indicate?12. Why is self medication not advisable for eyes?13. What are the vitamins which are beneficial to eye ?14. Which vitamin lowers the risk of developing cataract?15. How does melanin help the eye ? ARAVIND EYE CARE SYSTEM

Hand-held Autorefractometer 17 How to Use MeAuto refractometer The device consists of a measuring unit and a station. The station is provided with theAuto refractometer is a device that measures power supply, a charger and a printer to printobjective refraction, and contains the functions the measured results. The measuring unit isfor measuring spherical power, cylindrical provided with a color LCD monitor and apower and cylindrical axis. The measured control panel etc, to perform alignment andvalues of refractive errors are mainly used as a operation. To make measuring easier,an auto-reference for the lens prescription in spectacles chart function is available which will startand contact lenses for the correction of visual measurment automatically when the patient'sacuity. eye is aligned and focused. The built in RS -232C interface allows to send out data to aParts of Autorefractometer personal computer.• LCD Screen Indication• R/L Selection button - Memory button The model AR-20 auto refractometer is a - Eye mode selection button diagnostic device that is indicated for use in - Angle correction button the automated measurement of the eye. - Start button - Print button Special features - Parameter setting button - Power button • The hand held autorefractometer features - Grip a 2.5 inch color LCD with clear light weight focusing indicators. • The AL mode enables automatic and accurate measurment to be made. • 90 degree correction function. • Auto chart for accurate measuring. Processing • As with all instruments, the time taken depends much on the co-operation of the patient. • The average patient can have both eyes tested with in 3 to 4 minites. • Patient needs to fixate on the light. • The right and left eye data are captured simultaneously. Compassion July - Sep, 2014

18 • Bring the measuring unit clips to the patient's eye and place the forehead restPrinciple of refractometer against the forehead (top of eye brow).Light travels at different speeds through • Adjust the position of the measuring unitdifferent media and when a ray of light so that the patient's eye appears on thecrosses the interference between two LCD Screen.substances it changes direction.This is knownas refraction. • Make sure that the left eye(L) or right eye (R) indication is properly shown.Performing alignment • After measurment press the print button• Check the luminous spots on the cornea on the measuring unit. on the LCD Screen and perform alignment so that the central corneal luminous spot • The station will automatically transfer is placed inside the target. data a computer. • Measured data will be printed. Advantages • Portable and easy to use. • Fast and legible screening. • Compact station • Data memory for 30 persons • Wireless communication • Focusing indicator - Ms. M.Kaliammal Refraction Department, Aravind - TirunelveliARAVIND EYE CARE SYSTEM

Chain of Love 19 InspirationA man was riding his bike, when he saw an old lady, stranded on the side of the road. He sawthat she needed help. So he stopped his bike near her posh car and got out. He smiled, while he was approaching her. Still she was worried, as nobody had stopped forhours. Moreover, he did not look safe, as his appearance was so poor and shabby. He could see,how frightened she was, so he tried to calm her: “I‘m here to help you, don‘t worry. My name isJoseph John”. The tire was flat, so he had to crawl under the car. While changing the tire, he got dirty andhis hands were hurt. When the job was done, she asked how much she owed him for his help. Joseph smiled. Hesaid: “If you really want to pay me back, the next time you see someone, who needs help, givethat person the needed assistance. And think of me”. The same evening, the lady stopped by a small cafe. That place looked dirty. Then she sawa waitress, nearly eight months pregnant, wiping a table with a towel. The waitress had a sweetfriendly smile, although she had spent on her feet the whole day. Again and again, the lady was reminded of Joseph. How a person who has so little, can be sokind to a lady whom he did not even know. The lady finished her meal and paid the bill. The waitress went to get change and whenshe came back, the lady was gone. The lady had left a note on the napkin: „You don‘t own meanything. Somebody once helped me, just like now I‘m helping you. If you really want to pay meback, do not let this chain of love end with you”. The waitress found a few more money underthe napkin. That night the waitress came home earlier. She was thinking about the lady and the moneyshe left. She was wondering, how the lady could know, how much she and her husband neededit? Especially now, when the baby will soon arrive. She knew that her husband was alwaysworried about. So she was glad to tell him good news. Then she kissed him and whispered “Noweverything will be all right. I love you, Joseph John”. - Source: Internet Compassion July - Sep, 2014

20Answers to Quiz on Page 161. Infection and bleeding2. The eye tissue that encloses lens becomes cloudy and may blur the vision3. A laser is used to make a tiny hole in the eye tissue behind the lens to let light to pass through4. Cataract developed after exposure to some type of radiation5. - Cataracts that form after surgery for other eye problems such as glaucoma - Cataract formed in persons suffering from diabetes - Cataracts due to steroid use6. For near vision7. The lens is uniquely designed to provide enhanced image quality and a full range of vision- close, far away, and everything in–between–giving cataract patients the best opportunity to live life free of glasses.8. - Contrast is reduced in certain types of multifocals - Biometry must be very accurate - A period of adjustment is required9. Medications that increase the risk of bleeding during surgery10. When cataract prevents examination or treatment of another eye problem such as age –related macular degeneration or diabetic retinopathy11. Diabetes12. It will hold off symptoms which need treatment13. Vitamin A,C,E14. Vitamin C15. It brings vitamin A from the liver to the retina ARAVIND EYE CARE SYSTEM

The 8 Monkeys 21 Moral StoryMany a times we follow customs and traditions without taking a moment to think of their originand relevance in the modern age. Following our heritage and culture is definitely good; but blindbelief in superstitions will land us into trouble. The following story substantiates this clearly: Put eight monkeys in a room. In the middle of the room is a ladder, leading to a bunch of bananas hanging from a hook on the ceiling. Each time a monkey tries to climb the ladder, all the monkeys are sprayed with ice waterwhich makes them miserable. Soon enough, whenever a monkey attempts to climb the ladder, allthe other monkeys, not wanting to be sprayed, set upon him and beat him up. Soon, none of theeight monkeys ever attempts to climb the ladder. One of the original monkeys is then removed, and a new monkey is out in the room. Seeingthe bananas and the ladder he wonders why none of the other monkeys are trying to reach it. Butundaunted, he immediately begins to climb the ladder. All the other monkeys fall upon him and beat him silly. He has no idea why. A second original monkey is removed and replaced. The newcomer again attempts to climbthe ladder, but all the other monkeys starts attacking him brutally. Even the previous newmonkey also participates in the beating because all the other monkeys are doing it. However, hehas no idea why he’s attacking the new monkey. One by one all the original monkeys are replaced. Eight new monkeys are now in the room.None of them have ever been sprayed by ice water. None of them attempt to climb the ladder. Allof them will enthusiastically beat up any new monkey who tries, without having any idea why. And that is how traditions, religions and systems get established and followed.. Think twice before following a tradition, or system blindly… It would make more sense if weget our own understanding to it. - Source: InternetUndaunted - without any fear Compassion July - Sep, 2014

22 Situational AnalysisConsanguineous marriage and itsimpact on childrenGlaucoma is not something that can happen only to adults. It can occur in children too. Thecouple Nagarajan and Prema belonged to Kovilpatti. Theirs was a consanguineous marriage.They have 3 children. Their third son, Prakash right from his birth was having some problemswith eyes. His eyes were so sensitive to light and he hardly opened them. When he was just 10days old, the parents took him to a children’s hospital nearby. It was diagnosed that his corneawas really big with a different colour. The doctor asked the parents to take him to Aravind EyeHospital, Tirunelveli and gave a referral letter. On preliminary examinations at Aravind,Prakash was found to have glaucoma. Some moredetailed tests were necessary to confirm the disease. The doctor apprehended that his diseasecould be a result of his parents’ consanguineous marriage. Detailed examinations were conductedthe following two days. It was confirmed that Prakash was born with congenital glaucomaand that could be the reason for the abnormal cornea. Doctors suggested glaucoma surgery forPrakash. Counsellors explained his eye condition, surgery as well as the importance of properfollow up to his parents. Parents told that they would bring the boy for surgery the followingweek and went home. On reaching home, they discussed Prakash’s condition with theirneighbours. The neighbours assured them that surgery at this small age would be really riskyand the problem that he has now would be settled as he grew up. Listening to their words, theparents failed to bring the child for follow up. As Prakash grew up, he started tumbling upon things and falling down; his eyes grew moresensitive to light. Prakash could not play like normal children. He would always keep his eyesclosed and tears started coming. When the conditions worsened, Prakash’s parents brought himto Aravind – Tirunelveli. Due to increased intraocular pressure and not taking any treatment forthe past 2 years, his cornea again grew big, conjunctiva turned blue in colour and optic nervewas badly affected. The ophthalmologist suggested immediate surgery for Prakash. The parents were explained in detail about the surgery and its consequences. The doctorsalso made it clear that surgery could only control the pressure; vision lost could not be saved. Theparents were really upset that it was their ignorance that resulted in such a serious condition forPrakash. In a few days, surgery was done; initially in the right eye and then in the left. Parentswere also briefed on the importance of proper follow up. As the IOP was controlled, conjunctivaand cornea became normal. It is not that disease should be diagnosed at the right time; adherenceto adequate treatment and proper follow up would help save vision. Parents need to understand that their ignorance and delay in availing treatment will costtheir children’s life. Source: Sr. Kannamma Aravind - TirunelveliARAVIND EYE CARE SYSTEM

23FeedbackWe would appreciate your frank and open feedback, which will help us satisfy your needs in theforthcoming issues.Name: _____________________________________________Name of the Hospital / Institute: _____________________________________________Please indicate how satisfied you are with the following contents.(Please circle the appropriate number)S.No Contents Very Satisfied Neither Dissatisfied Very Satisfied Satisfied Dissatisfied nor dissatisfied 1 1 1 1 1. Clinical 5 4 3 2 2. Inspiration 5 4 3 2 3. It happened to me 5 4 3 2 4. Hot updates 5 4 3 2 1. Can you understand the English used in the journal? Yes No2. Are you interested in writing an article in this journal? Yes No If Yes, on what?_____________________________________________3. What other articles would you like to see in Compassion Journal? ______________________________________________________________4. Is there any difficulty in getting access to the journal? Yes No Compassion July - Sep, 2014