Trained Optometrists Research Articles

Impact of Different Visual Field Instruction Strategies on Reliability Indices

ABSTRACTPurpose: To investigate and compare the visual field performance following three different types of visual field instruction strategies.Method: Ninety consecutive visual field-naïve glaucoma patients who can perform the test and understand instructions were imparted three forms of instructions prior to the visual field test. Patients with visual acuity <20/200, central corneal opacities, or anterior segment pathology and patients unable to understand general instructions/uncooperative were excluded. All forms of instructions were given by a trained optometrist in the patients’ own language as an instruction leaflet read out in 5 min for a verbal group (group1) and by a 5 min video created in house (group 2). Group 3 patients were shown the video first, followed by verbal instructions. We evaluated the reliability parameters in each group after visual field testing by an independent optometrist blinded to the form of instruction given.Results: Among the three groups, group 3 patients had the least number of repeat tests. Eyes with MD<–12Db had better reliability than that of the other groups. Mixed-model linear regression analysis shows that the duration of the test was significantly influenced by the severity of glaucoma in group 1, which is further predisposed by false negatives (FN; β = 0.06, p < 0.0001, R2 61.7%).Conclusion: The video with verbal instruction can minimize the number of repeated tests compared with only verbal or only video instruction medium. The video as well as the combined video/verbal instructions have a practical influence of obtaining more reliable fields compared with only verbal instruction.

Outcome of universal newborn eye screening with wide-field digital retinal image acquisition system: a pilot study.

PurposeTo evaluate the outcome of universal newborn eye screening with wide-field digital retinal imaging (WFDRI) system.MethodsIn this pilot study, we examined 1152 apparently healthy newborn infants in the obstetrics and gynecology ward of a civil hospital in Eastern India over 1.5 years. The examination included external eye examination, red reflex test and fundus imaging by WFDRI (RetCam II, Clarity medical system, Pleasanton, CA, USA) by a trained optometrist. The pathologies detected, net monetary gain and skilled manpower saved were documented. The results were compared with three similar studies thus far published in the literature.ResultsOcular abnormality of any kind was seen in 172 (14.93%) babies. Retinal hemorrhage in 153 babies (88.9% of all abnormal findings) was the most common abnormality; it was bilateral in 118 (77.12%) babies and 4 babies had foveal hemorrhage. Other abnormalities included vitreous hemorrhage (n=1), congenital glaucoma (n=2), uveal coloboma (n=2), retinopathy mimicking retinopathy of prematurity (n=2), and cystic fovea (n=3). The retinal hemorrhages resolved spontaneously in all eyes. One baby with congenital glaucoma received surgery and the other was treated medically. The benefits included savings in skilled manpower, a net monetary gain of INR 4.195 million (US$ 62,612) and skilled manpower saving by 319.4 h.ConclusionsThe universal neonatal eye screening using WFDRI detected pathologies that needed immediate care or regular follow up; saved skilled manpower with a net monetary gain. But compared to a red reflex test the benefits were marginal in terms of detecting treatment warranting ocular pathologies.

Vision Profile and Ocular Characteristics of Special Olympics Athletes: Report from India

ABSTRACTPurpose: Previous reports, albeit isolated, of vision and ocular screening of athletes with intellectual disability participating in the Special Olympics, UK, indicated high rates of refractive error and ocular morbidity; however, there have been no reports of similar sports events for this population from India. This study set out to evaluate the vision profile and ocular characteristics of athletes with intellectual disability attending the Special Olympics Lions Club International Opening Eyes (SOLCIOE) event in 2012 in India.Methods: A cross-sectional study was conducted, where a protocol-based ophthalmological assessment was performed by trained optometrists at a tertiary eye care center.Results: Overall, 172 athletes (mean age 18.6 years, 70% male) with intellectual disability participated, and 138 (80%) were able to cooperate for complete or nearly complete vision and ocular assessment. A total of 56 (32%) had never had a previous vision or ocular health status examination. A total of 46 (32%) presented with low vision (World Health Organization definition <6/18 to 3/60 in the better eye), 21% needed a first or updated spectacle prescription, and 28% had significant ocular pathology as the cause of visual loss.Conclusions: The proportions of refractive errors and ocular disorders in athletes with intellectual disability attending the SOLCIOE program in South India are similar to those reported for able-bodied school-aged children in urban and rural India. Like that of their able-bodied peers, the visual needs of children with intellectual disability are also not adequately being met.

Prevalence and associated factors of presbyopia among school teachers in Gondar city, Northwest Ethiopia, 2016.

IntroductionPresbyopia is an age-related decline in accommodation that diminishes the ability of the eye to focus on near objects. This is due to reduced elasticity of the crystalline lens as age increases. It causes near-vision impairment and affects near work, so it has significant effects on quality of life, particularly in the life of teachers, whose work depends mostly on reading and writing at short distances.ObjectiveThe overall objective of the study was to assess the prevalence and associated factors of presbyopia among school teachers in Gondar city, Northwest Ethiopia, 2016.MethodsA cross-sectional study design with multistage simple random sampling technique was used to select 668 teachers in Gondar city. The study was conducted in 12 schools from April 15 to May 15, 2016. A pretested structured questionnaire and ophthalmic instruments for an eye examination were used as data collection tools by trained optometrists. Epi Info version 7 was used for data entry, and the data were exported to Statistical Package for Social Science version 20 for further analysis. Multivariate logistic regression was employed using enter method and odds ratio with 95% confidence interval, and p-value of ≤0.05 was considered to identify statistically significant associated factors of the outcome.ResultsPrevalence of presbyopia among school teachers was 68.7%. Out of the total examined subjects, 317 (50.2%) were females. On multivariate analysis, increased age, salary, work experience, cigarette smoking, pregnancy, and refractive error were positively and significantly associated with presbyopia. On the other hand, use of sunglasses and alcohol consumption were inversely and significantly associated with presbyopia.Conclusion and recommendationThe study had demonstrated a higher prevalence of presbyopia among school teachers. Further investigation is recommended to assess the effect of alcohol consumption on presbyopia.

Knowledge, attitude, practice and quality of life assessment in glaucoma- a cross sectional survey

Aim: To determine knowledge, attitude and practice of patients with glaucoma and to analyze the quality of life of patients with glaucoma using the GQL-15 questionnaire. Materials and Methods: 62 patients with a known diagnosis of glaucoma and started on medical management were included in the study. On the first visit patients were counseling about the nature of the disease, dose, duration and frequency of medications, were informed of side effects and technique of instillation. On the second visit patients were assessed with a validated KAP questionnaire and GQL-15 quality of life questionnaire. The questions were administered in the local language by trained optometrists and health care personnel. Results: The inter item correlation between knowledge, attitude and practice was found to be 0.897, 0.877 and 0.765 there by validating the questionnaire. Forty nine (87.5%) of patients were found to have adequate knowledge regarding disease, drug, dose , frequency and proper method of instillation of eye drops. Forty one (73.32%) of patients were found to have a positive attitude towards usage of eye drops and the remaining 15(26.78%) negative attitude. Safe practice was followed by 49 ( 87.5%) of patients and unsafe with 7( 12,57%) GQL-15 questionnaire applied at the time of second visit showed 40 (71.42%) of patients with low GQL score. Conclusion: Our study highlights that awareness and dissemination of information on basic eye drop instillation technique improves patient knowledge awareness and practice patterns of this asymptomatic disease and can help patients adhere to management.

Population-based assessment of visual impairment among ethnic Dai adults in a rural community in China.

Dai ethnicity is one of the major Chinese ethnic minorities with a population of about 1.2 million. We aimed to determine the prevalence and potential causes of visual impairment (VI) among ethnic Dai adults aged 50 years or older in a rural community in China. A population-based survey including 2163 ethnic Dai people (80.5%) was undertaken using a random cluster sampling strategy. The detailed eye examination was performed after pupil dilation by trained study ophthalmologists and optometrists. Presenting visual acuity (PVA) and best-corrected visual acuity (BCVA) was measured using the Early Treatment Diabetic Retinopathy Study logMAR chart and VI was defined as a VA of less than 20/63 in the better-seeing eye. The overall prevalence of presenting blindness and low vision was 3.0% (95% CI, 2.3–3.7) and 13.3% (95% CI, 11.9–14.8), respectively. The prevalence estimates were reduced to 2.1% (95% CI, 1.5–2.8) and 6.7% (95% CI, 5.7–7.8) when BCVA was considered. Men were more likely to be affected by low vision but less likely to be blind compared with women. Cataract accounted for 62.7% of presenting low vision and 68.8% of presenting blindness, respectively. In conclusion, VI was a significant health concern in Dai Chinese in China.

Resultados funcionales de la procuración corneal con fines de trasplante realizado por un licenciado en Optometría

IntroductionIn Mexico, availability of donated corneas is very low. In recent years there has been a decrease in corneal tissue importation creating a need in tissue harvesting among public hospitals. Due to a shortage of available ophthalmologists, trained optometrist could cover adequately this rising need. AimsTo analyze quality of corneal tissue harvested by a trained optometrist and to identify long term functional results in visual acuity and graft rejection rate in patients receiving those corneal tissues. MethodsPatients who received corneal tissues harvested by a single optometrist from January 2011 to November 2012 were included. Endothelial density was measured with specular microscopy. Initial and final visual acuity was measured using Snellen chart. Graft rejection presence was identified in all transplanted patients. Descriptive statistics was performed with Stata 10.0 Results25 corneas were harvested. 4 non-viable corneal tissues were discarded. 21 patients underwent corneal transplantation Mean preoperative endothelial cell count was 2834.76 cel/mm2 (SD±186.91). Three patients (3 tissues) (14.28%) had graft rejection. Mean preoperative visual acuity was 1.24 LogMar (SD±0.2923). All patients had visual acuity improvement in their last eye examination (p<.001) with a mean visual acuity of 0.52 LogMar (SD±0.3792). Mean follow-up was 34.85 months (SD±3.6). ConclusionsAll patients in this study had improvement in their final visual acuity. Corneal graft rejection rate was similar to frequency reported elsewhere. Trained optometrist could be ideal health professional to harvest donor corneas.

Epidemiology of Intermittent Exotropia in Preschool Children in China.

To determine the prevalence, subtypes, and associated risk factors for intermittent exotropia (IXT) in preschool children aged 3 to 6 years in eastern China. A population-based study including 5831 preschool children aged 3 to 6 years was conducted from 2011 to 2012 in Yuhua District, Nanjing, China, using an age-stratified random sampling procedure. Clinical examinations including ocular alignment, ocular motility, visual acuity, prism cover test, cycloplegia refraction, stereopsis screening, slitlamp examination, and fundus examination were performed by trained ophthalmologists and optometrists. Intermittent exotropia was defined as an acquired intermittent exodeviation of at least 10 prism diopters in an otherwise healthy child following the classification recommended by the National Eye Institute. The overall prevalence of IXT in this population was 3.24% (95% confidence interval, 2.79 to 3.69%), with no age (p = 0.19) and sex (p = 0.89) differences. Among 166 children with IXT, the "basic type" was the most common type of IXT (74.7%), the "divergence excess" was the second (19.9%), whereas the "convergence weakness" was the rarest (5.4%). In multivariate analysis adjusting for age, sex, and other confounders, the presence of IXT was only associated with a history of hypoxia at birth (odds ratio, 4.41; 95% confidence interval, 2.47 to 7.86). Intermittent exotropia affected approximately 1 in 30 Chinese preschool-aged children in eastern China, indicating a relatively higher burden of this pediatric eye condition in the world's most populous country. The presence of IXT was strongly associated with a history of hypoxia at birth.

Adequacy and relevance of Indian optometry curricula to practicing optometrists

Context: To ensure that future optometry graduates receive appropriate knowledge and skills to provide comprehensive primary eye care, it is important to evaluate the current optometry curricula. Aim: To evaluate the relevance of optometry curriculum in India by assessing the perceptions on the curriculum strengths and lacunae by practicing optometrists. Setting and Design: Questionnaire-based survey in India. Materials and Methods: A questionnaire was used to elicit the opinions of purposively selected, 4-year trained optometrists, on the adequacy, and relevance of the optometric curriculum subjects offered in the optometric institutions. Statistical Analysis Used: Descriptive analysis was used to show reported frequencies of single responses to questions. The Cronbach's alpha test was used to measure consistency of responses to questions. Results: One hundred and three valid complete responses were received. Fifty eight (56%) participating optometrists were females. The most adequately covered optometry subjects as reported by the participating optometrists were contact lenses (n = 87, 85%), refraction (n = 86, 84%), ocular investigation (n = 75, 73%), and ocular disease (n = 75, 73%). Ocular diseases, low vision, and dispensing optics were, reportedly, covered sufficiently in theory, but the participants lacked adequate practical exposure. Basic optics had a maximum score regarding practical exposure, among support subjects while communication skills, computer skills, and community optometry were rated very low. Business aspect and legal aspect were inadequately taught. The optometry curricula in India are considered as being adequate and relevant, some subjects need more practical demonstrations and teaching of support subjects needs amendments.

Prevalence and causes of reduced visual acuity among children aged three to six years in a metropolis in China.

To determine the prevalence and possible causes for reduced visual acuity (VA) in preschool children in a metropolis in China. A school-based paediatric eye survey including 5862 preschool children aged three to 6 years was conducted from 2011 to 2012 in Yuhuatai District, Nanjing, China, using an age-stratified random sampling procedure. Clinical examinations including ocular alignment, ocular motility, visual acuity, prism cover test, cycloplegic refraction, stereopsis screening, slit lamp examination and fundus examination were performed by trained study ophthalmologists and optometrists. Reduced VA was defined as presenting VA of worse than 0.30 logMAR (Snellen 6/12 or 20/40), for both better and worse eyes. 5667 (94.8%) children with complete VA data were included in the data analyses. Among them, 208 and 93 had reduced VA in the worse and better eye, respectively. Reduced VA was detected in 3.7% (95% confidence interval [CI] 3.2%-4.2%) in the worse eye and 1.6% (95% CI 1.3%-2.0%) in the better eye. No significant age and gender differences in reduced VA were observed (p > 0.05). Refractive errors and amblyopia were the principal causes for reduced VA in the worse eye which accounted for 66.8% and 32.7% of the total cases with reduced VA, respectively. Astigmatism and hyperopia were the major types of refractive errors causing reduced VA. The burden of reduced VA in preschool children in China was similar to that of Asian children of similar ages in the United States. Uncorrected refractive error and amblyopia were the principal causes for reduced VA among preschoolers (aged three to 6 years) in China.

Association between childhood strabismus and refractive error in Chinese preschool children.

PurposeTo investigate the association between concomitant esotropia or concomitant exotropia and refractive error in preschool childrenMethodsA population-based sample of 5831 children aged 3 to 6 years was selected from all kindergartens in a representative county (Yuhuatai District, Nanjing, Jiangsu Province) of Nanjing, China. Clinical examinations including ocular alignment, ocular motility, visual acuity, optometry, stereopsis screening, slit lamp examination and fundus examination were performed by trained ophthalmologists and optometrists. Odd ratios (OR) and 95% confidence intervals (95% CI) were calculated to evaluate the association of refractive error with concomitant esotropia and concomitant exotropia.ResultsIn multivariate logistic regression analysis, concomitant esotropia was associated independently with spherical equivalent anisometropia (OR, 3.15 for 0.50 to <1.00 diopter (D) of anisometropia, and 7.41 for > = 1.00 D of anisometropia) and hyperopia. There was a severity-dependent association of hyperopia with the development of concomitant esotropia, with ORs increasing from 9.3 for 2.00 to <3.00 D of hyperopia, to 180.82 for > = 5.00 D of hyperopia. Concomitant exotropia was associated with astigmatism (OR, 3.56 for 0.50 to 1.00 D of astigmatism, and 1.9 for <0.00 D of astigmatism), myopia (OR, 40.54 for -1.00 to <0.00 D of myopia, and 18.93 for <-1.00 D of myopia), and hyperopia (OR, 67.78 for 1.00 to <2.00 D of hyperopia, 23.13 for 2.00 to <3.00 D of hyperopia, 25.57 for 3.00 to <4.00 D of hyperopia, and 8.36 for 4.00 to <5.00 D of hyperopia).ConclusionsThis study highlights the close associations between refractive error and the prevalence of concomitant esotropia and concomitant exotropia, which should be considered when managing childhood refractive error.

A Prospective Study to Assess the Quality of Preliminary Eye Screening Done on School Children by Teachers in Andhra Pradesh

Aim: To assess the quality of vision screening done by trained schoolteachers on schoolchildren. Method: This study was carried out in Greater Hyderabad by selecting 10 schools in 3 different clusters by means of systematic random sampling. Teachers were imparted training for detecting vision defects and important ocular conditions and were permitted to screen the students using a protocol ascribed to them. Students who were screened by teachers were rescreened by optometrist to compare and analyse the outcome of the training imparted. Results: A total of 25 schoolteachers were trained and utilized for screening 600 students in age ranging from 8 to 13 (mean is 10.5 and ±SD is 1.87) girls constituting 55%. The impact of training increased knowledge level to 88%. Similarity found in detection of children with poor visual acuity <6/9 by both ‘the trained teachers and optometrist. Significant eye conditions which required early intervention were detected with the help of signs and symptoms learnt through the training (Kappa statistic=0.95) suggesting an excellent agreement among the teachers and optometrist. Conclusion: The study results suggest that trained teachers can be relied upon for screening children to identify various eye conditions including refractive errors. This study recommends incorporating a module on vision screening in the teachers’ education curriculum and conducting screening in schools on a regular basis.

No Evidence for Genetic Contribution of Ocular Dominance: The Guangzhou Twin Eye Study.

The purpose of this study was to explore the heritability of ocular dominance in a classic twin study. A classical twin study. Twins aged 7 to 19 years enrolled from the Guangzhou Twin Registry received comprehensive eye examinations. Ocular dominance was assessed by the "hole-in-the-card test" by trained optometrists. Zygosity of the participants was confirmed by genotyping in all same-sex twin pairs. The pairwise concordance rate was calculated as the main outcome. After excluding 110 children with anisometropia of 2.0 diopters or greater and 24 children with alternating ocular dominance, a total of 941 twin pairs were identified in the analysis, including 596 monozygotic and 345 dizygotic pairs. Right-eye dominance was present in 59.3% of twins with available data. The pairwise concordance rate was 0.529 and 0.530 in monozygotic and dizygotic twin pairs, respectively (P > 0.5). The tetrachoric correlation was 0.043 and 0.035, respectively. When comparing the young twins and their parents, no significant difference in the percentage of offspring with left-eye dominance was found between right × right parent mating group and non-right × right parent mating groups. Genetic factors may not be involved in ocular dominance in Chinese teens and children.

Repeatability of visual function measures in age-related macular degeneration

To assess repeatability of visual function measures in patients with early, intermediate or late age-related macular degeneration (AMD) without active neovascular disease in the study eye, but active neovascular AMD in the fellow eye. One hundred subjects from an ongoing trial were screened for this study in which their LogMAR acuity, contrast sensitivity and reading performance were assessed using standardised protocols by trained optometrists. The same measures were repeated one month later and repeatability of the visual functions assessed. Data from 83 subjects satisfied inclusion criteria for analysis. Coefficient of repeatability was 14.9 letters for LogMAR visual acuity , 7.2 letters for Pelli Robson contrast sensitivity, 0.72 for LogMAR reading acuity, 110.4 words/ min for reading speed and 0.67 for LogMAR critical print size. Intraclass correlation coefficients allowed comparison between measures and were found to be 0.96 for LogMAR visual acuity, 0.93 for contrast sensitivity, 0.75 for LogMAR reading acuity, 0.79 for reading speed and 0.74 for LogMAR critical print size. Coefficients of variation were 9.4%, 10.7%, 48.4%, 28.4% and 31.8% respectively. We found coefficients of repeatability that concurred with previous studies demonstrating variability of visual functions in patients with AMD. In addition, we found intraclass correlation coefficients to be better with visual acuity and contrast sensitivity than with measures of reading performance.

Prevalence and pattern of refractive errors among primary school children in Al Hassa , Saudi Arabia.

Some 12.8 million in the age group 5–15 years are visually impaired from uncorrected or inadequately corrected refractive errors. In Saudi Arabia, the size of this public health problem is not well defined especially among primary schoolchildren. The purpose of this cross-sectional study was to assess the prevalence and pattern of refractive errors among primary school children in Al Hassa, Saudi Arabia. A total of 2246 Saudi primary school children aged 6 to 14 years of both genders were selected using multistage sampling method form 30 primary schools located in the three different areas of Al Hassa. School children were interviewed to collect demographics and vision data using a special data collection form followed by screening for refractive errors by trained optometrists within the school premises using a standardized protocol. Assessment of visual acuity and ocular motility evaluation were carried out and cover-uncover test was performed. Children detected with defective vision were referred for further examination employing subjective refraction with auto refractometer and objective refraction using streak retinoscopy after 1% cyclopentolate. Of the screened school children (N=2002), the overall prevalence of refractive errors was 13.7% (n=274), higher among females (Odds ratio, OR=1.39, P=0.012) and significantly more among students of rural residence (OR=2.40, P=0.001). The prevalence of refractive errors was disproportionately more among those aged 12-14 years (OR=9.02, P=0.001). Only 9.4% of students with poor vision were wore spectacles for correction. Myopia was the most commonly encountered refractive error among both genders (65.7% of the total errors encountered). Uncorrected refractive errors affected a sizable portion of primary school children in Al Hassa, Saudi Arabia. Primary schoolchildren especially females, rural and older children represents high risk group for refractive errors for which the included children were unaware.

The role of optometrists in India: An integral part of an eye health team

India has a proud tradition of blindness prevention, being the first country in the world to implement a blindness control programme which focused on a model to address blinding eye disease. However, with 133 million people blind or vision impaired due to the lack of an eye examination and provision of an appropriate pair of spectacles, it is imperative to establish a cadre of eye care professionals to work in conjunction with ophthalmologists to deliver comprehensive eye care. The integration of highly educated four year trained optometrists into primary health services is a practical means of correcting refractive error and detecting ocular disease, enabling co-managed care between ophthalmologists and optometrists. At present, the training of optometrists varies from two year trained ophthalmic assistants/optometrists or refractionists to four year degree trained optometrists. The profession of optometry in India is not regulated, integrated into the health care system or recognised by the majority of people in India as provider of comprehensive eye care services. In the last two years, the profession of optometry in India is beginning to take the necessary steps to gain recognition and regulation to become an independent primary health care profession. The formation of the Indian Optometry Federation as the single peak body of optometry in India and the soon to be established Optometry Council of India are key organisations working towards the development and regulation of optometry.

Better Vision for the Poor

About 500 million to 1 billion poor people in the world need eyeglasses but do not get them. Visual impairment is more than just a health problem; it has economic, educational, and public safety implications. In 2005, the French multinational Essilor launched a 'bottom of the pyramid' initiative to market eyeglasses to the Indian rural poor. VisionSpring was founded in 2001 as a social enterprise with the mission to provide affordable eyeglasses to the poor. Another approach to solving the vision problem emphasizes technological innovation to provide low-cost self-adjustable spectacles. None of these approaches has succeeded on a large enough scale so far. We propose an alternative solution that emphasizes dramatic cost reduction by utilizing ready-made eyeglasses, basic screening without a trained optometrist, economies of scale, piggyback distribution, and low overheads.

Shared care in glaucoma: a national study of secondary care lead schemes in England

To determine the number and nature of shared care schemes for glaucoma and glaucoma suspects operating in England. A two-stage investigational process targeting all secondary-care ophthalmic departments with junior medical staff. An initial telephone contact for basic data (March 2006) was followed by a detailed questionnaire for completion by the scheme lead (May 2006). The telephone contact showed that of the 131 eligible ophthalmic departments, 76 claimed to be operating a glaucoma-based shared care scheme. Questionnaires were returned from 74 of the 76 departments claiming to run a scheme, showing that there were only 66 schemes operating in mid 2006 in association with 62 departments. Of these, 14 were community-based (predominantly run by trained optometrists) and 52 operated 'in-house' (predominantly involving nurses and optometrists). Most schemes were <6 years old and of the 30 schemes seeing new patients, 14 (47%) did not use gonioscopy as part of the assessment. In 8 schemes (12%), the shared care staff members were able to prescribe medication for glaucoma. In England, even before the outcome of the Department of Health shared care pilots had been published, approximately 50% of ophthalmic departments were running shared care schemes for glaucoma. However, most schemes contributed only modestly to the overall volume of glaucoma care, indicating that the majority of glaucoma-related consultations still occur directly with ophthalmologists. The Royal College of Ophthalmologists guidelines on gonioscopy are not being followed in almost half of the schemes seeing new patients.

Authors′ reply

Dear Editor, I am thankful to Kothari et al,[1] for taking a keen interest in our article.[2] We would like to clarify some of the issues raised in the rejoinder to the article. We screened all hospitals and opined that only hospitals which provided inpatient services would be included for the simple reason that such institutions would have the infrastructure to tackle any complications that may arise during surgery. The inpatient facilities do not pertain to specific beds for children but the availability of beds in general. This categorization does not exclude institutions providing ambulatory services and does not in any way mean that all children should be admitted for surgery. Such a categorisation helped us in excluding clinics where the infrastructure would be inadequate for surgery. When outreach camps have been stopped for cataract surgery, it would be important that more care is taken for pediatric surgery. The article clearly mentions that private eye care facilities were also accessed ‘quite often’ and not ‘more often’ which has an entirely different meaning. As is evident from the results presented, more pediatric surgery was done at NGO and government institutions than at private institutions. This is evident from Table 4 of the article[2] in addition to what has been mentioned in the text. The WHO endorsement of the team approach cannot be refuted for its conception. What we have mentioned is the need of a ‘team approach’ which includes not only the optometrists but also others like counsellors. We agree that a skilled pediatric ophthalmologist can manage in the absence of a trained optometrist. However this comes at a cost as the surgeon is then undertaking tasks which can be handled effectively by another member of the team. It is only if the pediatric ophthalmologist does not have much work to do that such an approach would be feasible. However setting up a pediatric ophthalmology unit in a hospital where the pediatric ophthalmologist does not have adequate work load is not tenable. In the centuries old history of ophthalmic practice, 1990 is recent and not ancient. Recent does not connote a one year or six month period. The point is well taken that at ‘mature’ pediatric ophthalmology units there would be a substantial amount of squint surgery compared to pediatric cataract surgery. This could also be due to the fact that most anterior segment surgeons are comfortable with cataract surgery but less confident of doing a squint surgery and therefore there would be more squint surgery at ‘mature’ centers. It should also be remembered that a proportion of squint surgery is done at older ages (more so for cosmetic reasons) and so would not be captured among children. Though the prevalence of all squints would be higher than pediatric cataract for the reasons mentioned above and the community perception where an obvious opacity in a child's eye (which may make parents seek attention) compared to squints where parents perceptions may be different could contribute to the difference. Also the number of ‘mature’ pediatric ophthalmology units would be limited in comparison to the size of the population in India. Because of the above, as mentioned by the authors, the proportion availing squint surgery may be low due to reasons best known to the parents. We have only presented the situation as it is and cannot sit in judgement on this issue as we do not have any supporting evidence regarding surgical preferences.

Can the Brückner Test be Used as a Rapid Screening Test to Detect Amblyogenic Factors in Developing Countries?

PurposeTo determine the usefulness of the Brückner test as a screening tool for detection of amblyogenic factors in developing countries.MethodsA double blind prospective study of 101 children aged 1 to 16 years attending the pediatric ophthalmology department of a tertiary eye care center. A trained optometrist masked to clinical findings of the subject performed the Brückner test in a dark room using a direct ophthalmoscope and compared differences in brightness of the pupillary reflex of both eyes. Subsequently, subjects underwent a complete ophthalmic examination by a pediatric ophthalmologist masked to the results of the Brückner test.ResultsThe optometrist identified 39 subjects as Brückner test positive and 62 as Brückner test negative. On clinical examination, 12 subjects had anisometropia of ≥1D and 20 subjects had manifest deviation of >4∧. The sensitivity of the Brückner test was 87.5% and specificity 84.1%; the positive (PPV) and negative predictive (NPV) value was 71.8% and 93.6%. The false positive and false negative rates were 28.2% and 6.5%.ConclusionAlthough imperfect, the Brückner test may be a low cost alternative to either screening with photo screener or to no screening for amblyogenic factors in developing countries.