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February 2016 Volume XXXIV No 1

Scientifi c Journal of

MEDICAL & VISION RESEARCH FOUNDATIONS

insight

www.sankaranethralaya.org Editor: Parthopratim Dutta Majumder

Sankara Nethralaya – The Temple of the Eye.

It was in 1976 when addressing a group of doctors, His Holiness Sri Jayendra Saraswathi, the Sankaracharya of the Kanchi Kamakoti Peetam spoke of the need to create a hospital with a missionary spirit. His words marked the beginning of a long journey to do God’s own work. On the command of His Holiness, Dr. Sengamedu Srinivasa Badrinath, along with a group of philanthropists founded a charitable not-for-profi t eye hospital.

Sankara Nethralaya today has grown into a super specialty institution for ophthalmic care and receives patients from all over the country and abroad. It has gained international excellence and is acclaimed for its quality care and compassion. The Sankara Nethralaya family today has over 1400 individuals with one vision – to propagate the Nethralaya philosophy; the place of our work is an Alaya and Work will be our worship, which we shall do with sincerity, dedication and utmost love with a missionary spirit.

insight

Scientifi c Journal of Medical & Vision Research Foundations

Year: 2016

Issue: Vol. XXXIV | No. 1 | February 2016 | Pages 1–28

Typeset at: Nova Techset (P) Ltd., Chennai, India

Printed at: Gnanodaya Press, Chennai, India

©Medical and Vision Research Foundations

ContentsGuest Editorial 1Krishnakumar R

Commentry: Role of optometrist in Eye Hospitals 2Krishnakumar R, Anuradha N, Jameel Rizwana Hussaindeen and Sailaja M V S

Short Review: Social accountability in Optometric Education 7Anuradha N and Krishnakumar R

Short Review: Innovations in Optometric Education 11Rashima A and Krishnakumar R

Recent Advances: Innovations and advancements in Refractive Error Measurement 15H. Sumeer Singh, K.S. Prahalad and A. Vijayalakshmi

Update: Update on Spectacle Lenses 18Viswanathan S

Major Review: Occupational Optometry Service – an Overview 20Krishnakumar R, Rashima A and Santanam P P

Short Review: A Tale of Intermittent Exotropia and Amblyopia – Does Vision Therapy Help? 23Jameel Rizwana Hussaindeen and Surendran T S

ESO at a glance

Inquiries or comments may be mailed to the editor at [email protected]

Guest Editorial

Dr R Krishnakumar

During the recent 3rd ESO’s International VisionScience and Optometry conference organised by EliteSchool of Optometry, one of my friends, who is alsoan optometrist, from Tripura shared with me thedocuments of 1920s which carried the informationabout the first school of optometry (Indian College ofOptics) in Calcutta by Mr K. D. Dutta in the year 1927.Until 1978, the focus of 2-year optometry programmewas to prepare refractionists for the country. In theyear 1985, the visionary Dr S.S. Badrinath started thefirst modern school of optometry called EliteSchool of Optometry (ESO) which started offeringdegree programme. Since then the extended role ofoptometrists started evolving and today we couldsee indispensible role of optometrists in eye hospi-tals and optical showrooms. The first masters pro-gramme was started in the year 1996 and later on

opening for doctorate and fellowship also werestarted. Today, to the best of my knowledge, thereare 30 universities all over the country offeringoptometry programmes either as undergraduate oralong with postgraduate programme. Many of theoptometrists with higher degrees take up academicand research roles in many of the universities andthe leading eye research centres in the country.

This special edition will be an opportunity tointroduce to the readers, the comprehensive roleof optometrists in eye hospitals, status and inno-vations of socially accountable optometric educa-tion, upcoming technologies in estimating refractiveerrors, unique role of occupational optometrist inthe industries, update information about ophthalmiclenses and an interesting case report by optometristin collaboration with ophthalmologist.

How to cite this article Dr R KrishnaKumar. Guest Editorial Sci J Med & Vis Res Foun 2016;XXXIV:1.

Correspondence:R. Krishnakumar, Principal,Elite School of Optometry,Unit of Medical ResearchFoundation, 8, G S T Road,St Thomas Mount,Chennai - 600 016.Email: [email protected]

Sci J Med & Vis Res Foun February 2016 | volume XXXIV | number 1 | 1

Guest Editorial

Role of Optometrist in Eye Hospitals

R. Krishnakumar, N. Anuradha, M. Jameel Rizwana Hussaindeenand M.V.S. Sailaja

Optometrists are important members of theeyecare team in an eye hospital. They take care ofa predominant portion in the outpatient services.The role of the optometrist in the hospital set-uphas expanded since its inception. In the early1980s, the principal role of the optometrist in thehospital set-up was the performance of clinicalrefraction, while the ophthalmologist would pre-scribe the glasses. The period from mid-1980s to theearly 1990s saw the evolution of optometry educa-tion into a degree programme that looked beyondbasic refraction into other aspects of outpatientmanagement. Today, optometrists play a comple-mentary role to ophthalmologists in the tertiary eyecare setup. With the addition of many more dimen-sions, it has developed into a multi-faceted role withever increasing scope and responsibility.

In a recent study in UK, the extended role ofthe optometrists in eye hospital was found to besignificant in the areas like glaucoma, macula,medical retina/diabetes, cataract and corneal ser-vices.1 A wide variety of clinical procedures areundertaken as part of these services with relativeautonomy.1 Moorfields eye hospital employs opto-metrists who are employed in roles involvingrefraction, low vision, contact lenses and clinicaltrials. Extended roles involve service in depart-ments such as cataract, external diseases, glau-coma, medical retina including diabetic screeningand management and paediatric services.2

As a frontline service provider in tertiary eyehospitalOptometrists are the frontline service providers ina tertiary eyecare hospital. They document history,perform clinical refraction, evaluate basic compo-nents of binocular vision, examine the anteriorstructures of the eye using the slit lamp biomicro-scope, and measure intraocular pressure using theapplanation tonometer and finally advise thepatients for dilatation. This first level of evalu-ation aids the ophthalmologist in diagnosis andarriving at an appropriate treatment plan follow-ing retinal evaluation. The optometrist thereforenot only performs a detailed ocular examinationbut also facilitates diagnosis, management ofmore patients by a single ophthalmologist andaccurate documentation of the entire procedure.

Optometrists are spread across the hospital indifferent clinics, namely general ophthalmology,glaucoma, neuro-ophthalmology, paediatric oph-thalmology, uvea, vitreo-retina, cornea, LASIK,

and oculoplasty. In each of these clinics, the roleof the optometrists as the first-line service provi-ders varies. In the glaucoma clinic, in addition todoing routine procedures, optometrists areengaged in additional diagnostic procedures suchas gonioscopy using Goldmann 4-mirror gonio-scope and indicate or perform any additional teststhat may be needed. A study at the Moorfields EyeHospital of four resident optometrists and threemedical clinicians showed that of the 50 patientsexamined, agreement between optometrists andconsultants in glaucoma clinical decision makingwas at least as good as that between medical clini-cians and consultants.2 The study opined thatwithin an appropriate environment, optometristscan work safely as part of hospital glaucoma teamin outpatient clinics.2 Similarly, in patientsshowing signs such as strabismus, ptosis, red eyes,watery eyes, etc. the relevant clinical evaluationperformed by the optometrist to document thefindings enables accurate diagnosis.

Optometrists in the diagnostic arena intertiary eye hospitalOptometrists play more than a technician’s role inhandling various instruments in a tertiary eye carehospital. They handle almost all the diagnosticinstruments in the clinics. The advantage of addingtheir interpretation in all diagnostics reports is auseful contribution in busy set-ups such as the ter-tiary eye care hospitals in India. Presently theyhandle automated perimeter, ultrasound biomicro-scope, electrophysiological instruments and variousimaging devices from anterior to posterior aspects ofthe eye. Given that their education includes anunderstanding of the pathophysiology of ocular dis-eases, their ability to perform the test and interpretthe reports is unparalleled. Highly qualified and pas-sionate optometrists have contributed enormouslyby enhancing the quality of the services in theseset-ups on many occasions.

As a biometrist in tertiary eye care hospitalPatients who are advised for cataract surgery arereferred to the biometrist. Biometrists measurecorneal curvature and axial length and calculateintraocular lens power using appropriate formulafor the surgeon’s targeted refractive outcome. Thechallenges of adopting appropriate procedures toarrive at the right IOL power among patients whohave a history of corneal refractive surgery, sili-cone oil in-situ or a corneal opacity is one of the

Correspondence:R. Krishnakumar, Principal,Elite School of Optometry,Unit of Medical ResearchFoundation, 8, G S T Road,St Thomas Mount,Chennai - 600 016.Email: [email protected]

2 Sci J Med & Vis Res Foun February 2016 | volume XXXIV | number 1 |

Commentary

major ways in which optometrists contribute tothe success of cataract surgery. In addition, theyalso play a supporting role in selecting premiumintra ocular lenses like multifocal and toric lensesthat would be appropriate for the patient.

As an independent vision care provider intertiary eye care hospitalIndependently, optometrists evaluate patientsrequiring a regular eye check-up and prescribeglasses. In case of no indication for a dilated eyeexamination, the central “retina” is evaluatedusing a direct or non-mydriatic ophthalmoscope.Patients are further appropriately referred toophthalmologists or other appropriate health careprofessionals when required.

As a contact lens care practitionerOptometrists also independently counsel, fit pre-scribe and dispense contact lenses in a tertiary eyecare hospital. The patients are generally referredby ophthalmologists from various internal clinicsand/or from outside hospitals. The uniqueness ofcontact lens practitioners in such centres lies notonly in handling patients with simple refractiveerror but also in fitting contact lenses for the spe-cialized and complicated cases. Prescription ofvarious contact lens types such as toric lenses (forastigmatism), multifocal lenses, contact lenses forirregular corneas, myopia control contact lensesetc. are commonly handled in this clinic by theoptometrist trained in this specialty.

As a low vision care practitionerThis is a core area for the optometrist in the area ofvision rehabilitation. With the advent of newertechnologies, optometrists play a significant role forpeople with irreparable vision loss by understandingtheir day-to-day visual needs and provide themwith appropriate low vision care interventions and/or other forms of rehabilitation. They also teach,educate the patient about the usage of these noveldevices and therefore enable patients to use theirexisting vision in accomplishing daily visual tasks.Children with multiple disabilities and visionimpairment need special attention from optometristsspecialized in vision development to attend to theassessment and management of visual issues.

As an occupational optometry practitionerOccupational optometrists in the industrial set-upare vital in pre-employment vision care services,provision of periodic eye care and in the develop-ment of vision standards for various occupations.The step-by-step clinical approach for this special-ization is discussed in another article in thisissue.3

As a binocular vision care providerThe advent of technology has caught up with thegrowing needs of every individual from birth. Onthe one hand, this has brought updated informa-tion to fill the dearth of knowledge, but on theother hand it has placed additional demands onthe visual system to retain its efficient functional-ity. Recent epidemiological and clinical data showthe prevalence of binocular vision anomalies to beat an alarming 30%,4 almost six-fold more thanthe need for refractive correction. This emphasizesthe need for a trained team of optometrists todiagnose and manage these non-strabismus bin-ocular vision anomalies. These optometristswould focus on enhancing the visual skills neces-sary for reading, learning, sports and all visuallydemanding tasks requiring binocular vision andstereopsis.

The scope of binocular vision care is not justlimited to the clinic. It can be taken to the com-munity at the level of work place of an individualor to the school set-up of children. Occupationalvision care specific to binocular vision demands4

requires optometric expertise. Models of vision carehave been developed to establish this set-up in acomprehensive, feasible and structured way. Childrenwith special needs such as reading and learning dis-ability are highly vulnerable to the development ofvarious visual issues. Binocular vision anomaliesare highly predominant in this population, thusdemanding the role of optometrists in the thoroughassessment and management of these anomalies.The optometry team have an ever expanding andnever ceasing demand in these arenas of clinicaland community care of binocular vision.

Vision therapy, the art of training the accommo-dation, vergence, oculomotor and deficient visualfunctions requires the care and attention of optome-trists. This is because they understand the complexfunctionality of the binocular visual system and thescientific basis of vision therapy so as to customizethe vision therapy for every individual.

Neuro-optometry careNeuro-optometry clinic is the brain child of anadvancing era of binocular vision clinic. Thisclinic comprising of the multidisciplinary team ofneuro-ophthalmologists, neurologists, neuro-opto-metrists and vision therapy team seeks to advancethe art and science of visual rehabilitation of theneurologically challenged population. 60% oftraumatic brain injuries in India is attributed toroad traffic accidents (RTA), with mortality andmorbidity rates of 0.12 million and 1.27 million,respectively.5 Binocular vision anomalies such asconvergence insufficiency (CI), accommodativeinsufficiency (AI) and saccadic dysfunction arecommonest sequelae after the injury.6 In such ascenario, neuro-optometry care is essential toserve this neurologically challenged population in


Commentary

aspects of diagnosis, optometric management andrehabilitation.

Amblyopia clinicThe understanding of amblyopia has moved onfrom simple visual acuity deficit to deficits ofhigher levels of visual processing. It is now termeda syndrome, rather than a condition. With bettercharacterization of the deficits, there is enhancedunderstanding of the plasticity of the visual systemand options in the treatment of amblyopia.Optometrists as vision scientists along with paediat-ric ophthalmologists can effectively tackle this bycomprehensive assessment of visual functions andby laying out an appropriate structure of treatmentto restore the visual functions of the amblyopicvisual system. Does this pertain only to a child’svisual system? Definitely not. Recent researchessuggest that matured brain of an amblyopic visualsystem also has the potential and plasticity torespond to treatment through perceptual learning.7

Perceptual learning modifies the receptive fields ofcells of the visual cortex in the brain through astronger stimulation. Our clinical experience at theSrimathi Sundari Subramanian Department ofVisual psychophysics at Sankara Nethralaya hasaided in better understanding of this new treatmentfor adult amblyopia. After 20 h of a first personaction videogame play, we observed improvementsin visual acuity, contrast sensitivity of the ambly-opic eye and also in the stereo acuity in anisome-tropic amblyopes. Improvement in visual acuity inthe amblyopic eye ranged between 1 and 1.5 linesof log MAR visual acuity.8 Through their in-depthunderstanding and by application of current find-ings in vision research, optometrists could make adifference in the assessment and management ofamblyopia.

Myopia clinicThe sweepingly increasing prevalence of myopiaworldwide has resulted in a corresponding interestin myopia research. The amount of research hassteadily progressed with myopia progression andprevalence compared to a decade-old data. Thistrend warrants the need to understand theethnicity-specific mechanisms behind myopia inour population. Optometrists’ contribution in thisspecialty does add a lot of value in planning afuture template for myopia treatment. Literaturereports contain strong evidence that reducedoutdoor exposure is one of the causes of increas-ing prevalence of myopia worldwide. The optome-trist’s role in bringing in awareness among theparents for their children on this aspect is indis-pensable. There are various myopia control inter-ventions which are coming into practice in whichthe optometrist serves as a key player in offeringthe clinical services to children.

Understanding the mechanisms of binocularvision anomalies as a researcherIn a tertiary eye care set-up, optometrists as visionscientists contribute to the understanding of binocu-lar vision anomalies through research thus paving theway for structured treatment protocols. As detailedabove, binocular vision anomalies such as conver-gence insufficiency, amblyopia, eye movement disor-ders due to neurological damage and myopia requirethe attention and care of the specialty optometryteam in a tertiary eye care set-up. The clinical care ofthese anomalies when backed up by scientific evi-dence from the research team would bear testimonyto the benefits of evidence based practice in eye andvision care. Optometrists should utilize the tertiaryeye care platform to expand, spread and explore thesepathways thus strengthening the role of optometristsin the eye/vision care spectrum.

Concept of review clinics in tertiary eye carehospitalIn the clinical set-up, a review clinic run by anoptometrist can cater to individuals who are comingfor review or follow-up check-up, so as to accommo-date new patients in the outpatient department. Inthe review clinic, the optometrist can review the pre-vious records of the patient and evaluate the ocularstatus as per the protocol of the respective clinic andif found to be clinically stable can counsel thepatient accordingly. Only for those patients, whohave clinical findings significantly different (as perthe clinical protocol) from the previous visit, referralto the appropriate ophthalmology specialist wouldbe required. This would help the system to accom-modate new patients who seek consultation withthe specialized ophthalmologist to a large extent.Glaucoma review clinic and Amblyopia clinic aresome of the clinics which appropriately fit into thereview clinic systems of a tertiary eye care system.

The role of optometrist in pre- and post-surgicalprocedures and counselling in hospital set-up areevolving as an extended role of the profession. Withthe advent of many types of intraocular lenses, theoptometrist can be an appropriate professional toexplain in detail the various types of the lenses tohelp in decision-making of the patient. They wouldalso be good choice to explain about the advantagesand limitations of various interventions suggestedby the ophthalmologists.

Another upcoming extended role of optome-trists is in the area of dry eye. Optometrists couldadminister the ocular surface disease (OSD) ques-tionnaire, do appropriate eye tests and arrive atthe diagnosis. If diagnosis is confirmed, the opto-metrists would refer to the ophthalmologists forappropriate intervention.

As a dispensing opticianOptometrists play a very important professional rolein the optical services in tertiary eye care hospital.


Commentary

Once the patient brings the glass prescription, theoptometrist guides the patient through the process ofselecting appropriate lens and frame materials as wellas the type or design that would suit the individualcosmetically and fit adequately. This is an art by itselfand the role of optometrist is undoubtedly importantin such a set-up. Optometrists are also needed toensure the quality of the glasses that come from thedispensing workshop before being delivered to thepatient. In such a set-up, the optometrist ensures thatthe vision with the new spectacle is as per the pre-scription. If the vision is not as desired, the process ofidentifying the reason within the optical set-upbecomes easy and avoids unwarranted delay for thepatients. Moreover, optometrists are better suited toplay an administrative role in the optical services oftertiary eye care hospital due to their know-how.

As an ocularistOptometrists with an inclination to art, especiallyto drawing and painting, are found to be contrib-uting immensely in this clinic. This is a clinicwherein the one-eyed patients get custom-madeartificial eyes that match with the fellow eye cos-metically. Usually this clinic is run in associationwith oculoplasty and ocular trauma clinics of ter-tiary eye care hospital.

As a community outreach optometristOptometrists in tertiary eye care hospitals also playa significant role in the outreach activities of thetertiary eye care hospital. From coordinating, super-vising and executing the outreach programme, theyare the part of the vision care team in a variety ofoutreach programmes – school vision screening,cataract screening, diabetic retinopathy screening,glaucoma screening, tele-screening, mobile eye sur-gical unit, etc., Optometrist innovate in the outreachactivities. For example, the “One-Day Mass VisionScreening” concept is one such innovation.9 Theidea of including exclusive binocular vision screen-ing among the school children to screen for binocu-lar vision anomalies that could possibly interferewith reading and therefore impact academic per-formance was also the contribution of the optom-etrist. Apart from screening, creating awarenessamong the public on common eye ailments throughinnovative methods like installation of vision chartsin public places and door to door awareness ses-sions are also part of outreach. Training volunteers,school and college children as “vision ambassadors”on basic vision screening are a worthwhile initia-tive. Optometrists will have a huge role to play inmobile eye clinics which can provide comprehensiveeye care services at the doorstep of the patient andespecially for those who are bed-ridden.

As a vision science researcherOptometrists in tertiary eye care hospital also play arole as a vision science researcher. They collaborate

with other vision scientists and do fundamental,clinical and public health-related researches. Theircontributions in glaucoma, cataract, refractive error,amblyopia, occupational health, contact lens care,low vision care, binocular vision care, communitycare, diabetic retinopathy and other retinal condi-tions are routine. Optometrists are also steppinginto integrated research with basic science research-ers thus paving the way for translational research –

the need of the hour.

As educators in tertiary eye care hospitalOptometrists with adequate clinical experienceusually involve in teaching new comers and thestudents. They actively participate in clinicalgrand rounds and regular classes for the students.They also are part of the team, organizing scien-tific conferences and regular continuous medicaleducation.

As administrative personnelOptometrists’ play the administrative role of man-aging various optometry clinics within a tertiaryeye care hospital. In addition to the clinical ser-vices, they head specialty clinics such as lowvision care, binocular vision care and contact lensclinic. They are capable of donning an administra-tive role and help in planning further expansionin an eye care hospital.

In conclusion, the role of optometrist in tertiaryeye care hospital ranges from predominant clinicalroles in refraction, low vision care and binocularvision care, to extended roles in various clinics,education, research, training and administration andfurthermore up to changing the scenario of tertiaryeye care services in the country. This integrated roleof optometrists catering to the vision care needsand ophthalmologists attending to medical needs ofthe patient within a tertiary eye care set-up estab-lishes a healthy foundation for the expansion anddevelopment of the eye care profession for the bet-terment of the needy at large.

References1. Harper R, Creer R, Jackson J, Ehrlich D, Tompkin A, Bowen M,

Tromans C. Scope of practice of optometrists working in the UKHospital Eye Service: a national survey. Ophthalmic Physiol Opt2015 [Published Online]

2. http://www.optometry.org.au/media/275249/guideline_-_working_in_hospitals.pdf (accessed on 20 January 2016)

3. Santanam PP, Krishnakumar R, Monica R. Dr PP Santanam’stext book of occupational optometry. Chennai: MRF, 2015.

4. Hussaindeen JR, George R, Swaminathan M, Kapur S,Ramani KK, Scheiman M. Binocular vision anomalies andnormative data (BAND) in Tamil Nadu – study design andmethods. Vision Devel Rehab 2015; 260–270.

5. Madhavan R, Hussaindeen JR. Binocular vision issues in visualdisplay terminal users: In P.P. Santanam’s Text Book ofOccupational Optometry, 2015; 205–218.

6. Rashid AF, Fazili RA. Two-year study on road traffic accidentcases admitted in skims medical college hospital bemina.JK-Practitioner 2013; 18(3–4): 15–9.


Commentary

http://www.optometry.org.au/media/275249/guideline_-_working_in_hospitals.pdf




7. Revathy M, Ashwini VC, Hussaindeen JR, Priyadarshini D.Management of convergence insufficiency and oculomotordysfunction: a neuro-optometric perspective. Opt VisPerformance 2016 (In press).

8. Hussaindeen JR, Rakshit A, Negiloni K. Amblyopia: what elsebeyond patching and critical period. Sci J Med Vis Res Found2015; XXXIII: 132–134.

9. Rakshit A, Negiloni K, Agarkar S, Hussaindeen JR.Improvement and sustainability of visual functions with actionvideogame play in an adult with amblyopia: a case report. Int JHealth Sci Res 2015; 5(11): 464–467.

10. Anuradha N, Krishnakumar R. Role of optometry school insingle day large scale school vision testing. Oman J Ophthal2015, 8(1): 28–32.

How to cite this article Krishnakumar R, Anuradha N, Jameel Rizwana Hussaindeen M, Sailaja M.V.S. Role ofOptometrist in Eye Hospitals, Sci J Med & Vis Res Foun 2016;XXXIV:2–6.


Commentary

Social accountability in optometric education

N. Anuradha and R. Krishnakumar

Medical education needs to be socially responsible,socially responsive and accountable according toGlobal consensus for social accountability ofmedical schools document.1 Social responsibility isto be aware of the needs of the society. Socialresponsiveness is aligning the education, researchand service arenas with the needs of the commu-nity. Social accountability is aiming for the betterhealth of the society through partnerships with theGovernment initiatives, non-government organiza-tions and community partnerships.

Based on these expectations from the medicaleducation, vision of optometric institutions shouldrealign with these needs. Keeping up with thisgoal, Elite School of Optometry (ESO) defined its‘Vision’ as:Be always a foremost and distinguished leaderwith social responsibility, responsiveness andaccountability in optometric education, visioncare service and vision science research inIndia.This article aims to project the model by which

outreach initiatives of ESO are intertwined withacademics and research environment to providean integrated solution to the society’s needs andits march towards social accountability.

Integrated approach of outreach activitieswith the optometry curriculumIts implementation at ESOEducation should understand the developmentalpriorities of the nation and align the curriculumwith the promotion and development of commu-nities’ needs specifically in health care. Societalneeds are constantly increasing. Elimination ofpoverty, improved quality of life, disease preven-tion and health promotion are few of the needsfaced by the society. To provide a solution tothese needs, institutions should provide a platformfor development and application of expertise.Education should also ensure participatory learn-ing through authentic experience.2

With easy availability of knowledge, access toinformation to all the societal members, andexpectation of lifelong learning from the healthcare providers, the role of institutions becomesimportant in realizing the critical needs of thesociety, upgrading knowledge, dissemination ofknowledge, application of knowledge and partner-ing with organizations for sustaining knowledgeapplication.3 Outreach activities are such platformswhere scholarly expertise are generated, extended,applied and shared. It is an extension of the

expertise to the society’s needs with social respon-sibility and responsiveness.

On the other hand, it is not always one sided,knowledge also has to flow into the institutionfrom the society.3 Outreach activities need to beevaluated to understand its success and impact.The outcome measures of the impact or success ofthe research and service must be acceptable to thesociety and therefore should come from thesociety, which makes knowledge inflow crucial.Hence the broad areas of outreach are not limitedonly to service but also include academic andresearch initiatives.

Institution, faculty, students and communityare all part of the integrated approach in outreach.Though exact data on the proportion of contribu-tion of each faculty and participation of studentsin these three areas are yet to be measured, facultyand students contribute to the entire three arenaswith the dominance of clinical service owing tothe attachment of ESO to the tertiary eye carecentre, Sankara Nethralaya. Keeping in mind theneeds of the society, projects were designed in allthe three fields, which are briefly outlined.

AcademicsThe need for primary eye care in India is everincreasing and robust training is essential in thedelivery of such services. Early clinical experienceand bed side learning are emphasized to achieveit. Evaluation of the training process and examin-ation of the adequacy of the training warrantsspecial attention. Competency standards extendedby the associations of the profession also clearlyelaborates the objectives of the courses, enumer-ates the hours of clinical training, planning forevaluations, and expectations from the candidatesat the end of the programme.4

With the intent of complying with the objec-tives required of the profession, curriculum of theinstitution is revisited to make sure of its rele-vance to the context needed for the society. Scopeand objectives are laid down not only for thelecture courses but also for the clinical trainingsessions. Target numbers to be achieved in each ofthe clinical specialties are enumerated for all theundergraduate courses. Maintenance of log booksand continuing medical education is mandatory toensure systematic learning and constant updatingof knowledge. Visit to industries related to theoptical and contact lens fields, industries forunderstanding occupational health set-ups,rehabilitation centres adds value to the knowledgeacquired in those courses and also paves way for

Doctoral Researcher, Lecturer,Elite School of Optometry,Unit of Medical ResearchFoundation, 8, G S T Road,St Thomas Mount,Chennai - 600 016

Correspondence:N. AnuradhaEmail: [email protected]


Short Review

real life understanding. New initiatives like “BasicClinical Optometry skills Training” (BCOST) wasintroduced to initiate early learning of the optom-etry procedures. It is an attempt wherein seniorundergraduate students teach the juniors and vig-orously practice the enumerated procedures.Teaching ensured that the senior students under-stand the procedures and pass it on to the juniorsand the activity is monitored by the post-graduatestudents and faculty. Clinical evaluations aremade rigorous by methods like OSPE/OSCE[Objective Structured Practical Examination/Objective Structured Clinical Examination]. OSPE/OSCE, a common evaluation tool in medical edu-cation, has been in use at ESO for 4 years, ensur-ing every component of the skills to be evaluatedfor each student within a short span without anybias.

Attempts are not limited to providing educationto the students of the institution but also extendedto the community, where in interested students ofthe schools, colleges and volunteers from thecompanies are given training for Basic VisionScreening and also given awareness. These volun-teers help not only in screening for vision impair-ment but also act as ambassadors of theinstitution to the society on eye care. Visionambassadors who underwent such training are anasset to the institution and help partner with otherorganisations and also carry forward the vision ofthe institution to a wider audience.

ResearchResearch activities should aim at identification ofthe needs of the society and development of aresponse to the need. If not, the results of theresearch might not be appealing to the society andthe connect between the institution and thesociety will be at stake.3 Sankara Nethralaya, ouralma mater has always been in constant supportof India centric research, appealing to the massesof the country.

Research initiatives of ESO are introduced rightfrom the undergraduate level and extend as postgraduate and Doctorate programmes. Identificationof research projects are done with the objective ofIndia centric research in mind. Needs in the societylike lack of vision standards for various occupa-tions, lack of compliance to management strategiesin school vision screening, lack of man powerresources in community service, lack of validatedcharts for assessment of vision impairment, lack ofunderstanding about the preferences of the benefi-ciaries about the management strategies has led tovarious projects like vision standards of variousoccupations like watch-repairers and goldsmiths,innovative approaches in improving spectacle andreferral compliance in school screening, role ofoptometry students in single day school screening,understanding about eye care seeking behaviour

and construction and validation of various visualacuity charts in the vernacular languages. ESO hasalso considered knowledge-sharing to the extendednation and the world with other optometric frater-nity through its national and internationalconferences.

ServiceService is a platform encompassing the four areasof outreach: identification of a need, developing aresponse, planning a strategy and implementation.Knowledge gained through the academic curricu-lum and insights from the research need a plat-form to be extended and implemented so that thebenefits accrued are shared with the communityto whose needs these results were aimed at.Outreach activities aim at such implementationwith the design of a strategy and present or carryout the implemented plan. Optometry curriculumcombines various courses classified as Basicsciences, core optometry courses, applied optom-etry courses and support courses. Though thelearning objectives of all these courses aim atdelivery of knowledge in the relevant fields, itrequires an interdisciplinary approach to convergeit to achieve the aims of the outreach. Communityalso provides avenue for new research ideas andopen up opportunities for funding.

Service programs of ESO include school screen-ing, comprehensive eye camps, awareness cam-paigns on health promotion and diseaseprevention. When the need for elimination ofrefractive error arose, ESO started its schoolscreening initiatives partnering with theGovernment’s initiatives under the “National pro-gramme for Control of Blindness”. Designing aprotocol for the school screening, introducingnovel methods like involving optometry studentsin the screening, formulating cost-efficient strat-egies like single date screening, upgrading theprotocol like binocular vision anomalies screeningare all responses to the identified needs in theschool screening programme.

ESO also partners with non-governmentalorganizations to provide comprehensive eye campsand ensures a sustained model for the benefit ofthe public through the partnership. Ensuring thesupport of infra-structure and running the campsthrough the NGOs have ensured sustenance. Anadded advantage is the involvement of volunteersin such service initiatives from the partneringinstitutions. This has also helped in fund-raisingand infrastructure building of the institution.

In a unique delivery design strategy awarenessinitiatives have employed innovative models likedoor-to-door awareness campaigns, installation ofvision charts in the public places and creation ofcalendars with vision tests for use by public. Suchstrategies ensure exploring new ideas to be imple-mented, new strategies to be designed, aid in


Short Review

public exposure initially, enlighten the students oftheir role as primary care provider in health edu-cation and disease prevention, help in applyingconcepts learnt and Integrate the learning fromvarious streams to implementation.

A unique initiative by ESO on the service deliv-ery is the utilization of all academic faculty andnon-academic staff into the service initiatives.Aptly named “Aikya” which means integration, itimparts the idea of social accountability andresponsibility among everyone in the institutionand therefore makes an inspiring model for thestudents. Such initiatives stimulate the students tobe naturally responsive to the needs of the societyand the nation at large. This also provides oppor-tunity for sharing other subject matter faculty’sexpertise with community partners. Session onimproving communication among students andteachers was held by the communication facultyin a school where the screening activity tookplace.

Such activities motivated the students to showtheir commitment to the society through RotaractClub activities like arranging guest lectures ondiverse topics, visit to orphanage and spending aday with them, and visit to a home of HIVaffected children for Diwali celebration.

Benefits earnedIt is essential that such benefits are analysed andspread to the society at large to ensure the wide-spread reach of the importance and need of out-reach initiatives to the community.

STUDENT BENEFITSAcademic benefitsOutreach provides an opportunity for holisticapproach, understand relevance of academiccourse work, apply research skills in community,able to adapt to limited technology to addressissues, gain newer knowledge which are not con-fined to text books and understand the limitationsof academics and ability to face real-lifescenarios.6

Skill-based benefitsIt also ensures adequate practice of skills undersupervision, improvement in language ability,learning to work as a team and explore differentplaces through travel to service sites.

Impact on attitudesStudents feel great having helped the needy, gainadvantage of enhanced critical thinking, developinter-personal relationships, ability to socialize,can overcome conflicts, understand adjustmentsneeded in real-life practice, get rid of fear offacing people, ability to face problems, developsensitivity to critical and pressing societal issuesand understand needs, change in mind-set for

future career and enhanced empathy, patience,tolerance and confidence.

Professional benefitsExperience gained through the outreach initiativesadd to the curriculum vitae and enhances employ-ment or higher education opportunities.

FACULTY BENEFITSOutreach also opens up possibilities for newresearch in a resource limited setting, way forlimited budget projects and also provides anopportunity to interact and understand the stu-dents better.

BENEFITS TO THE INSTITUTIONIt helps in fulfilling mission and vision of theinstitution, aids in institution-community partner-ing, increases publicity and visibility and therebyin enrolling quality students.

COMMUNITY BENEFITSMotivated individuals are usually part of satisfy-ing the needs of the community and volunteer forsuch initiatives. It ensures completion of targetactions, emergence of sensitised individuals tocommunity needs, who will be able to deliverbetter to the community. Innovative, creativethinking brought about by diverse players andvolunteers brings about a new outlook of theneeds and “out of the box” ideas to face the chal-lenges and provide solutions. Increased awarenesson potential issues is an added benefit.

“A mediocre teacher tells. A good teacherexplains. A superior teacher demonstrates. A greatteacher inspires.” As this famous saying goes, out-reach programmes not only pave way to explainand demonstrate what was taught in the classrooms but also inspire the students towards value-based education. It forms the platform on whichthe knowledge and skill gained by the student isrightly implemented with the necessary attitude.

In the long run, institutions will have to play abigger role in contributing to the better of thesociety and the nation. Looking at a broaderpicture, a new outlook on the curriculum reflect-ing the needs of the nation, redefining our scopesand objectives, recognizing teaching strategies andplanning for country-centric research is essential.This should aim at preparing the student for theworld through streamlined educational experienceand kindle him for life-long learning and contrib-ute to a global outreach.

REFERENCES1. http://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/

11-06-07-GCSA-English-pdf-style.pdf (accessed on 3 February2016)

2. Gutstein J, Smith M, Manahan D. A service-learning model forscience education outreach. J Coll Sci Teach 2006; 36: 22–26.


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http://healthsocialaccountability.sites.olt.ubc.ca/files/2011/06/11-06-07-GCSA-English-pdf-style.pdf









3. Fulfilling higher education’s covenant with society: The emergingoutreach agenda https://ctools.umich.edu/access/content/group/1106364909396-12033726/Sandmann_L_FulfillHighEdCovenant.pdf (accessed on 4 January 2016).

4. Association of Schools and Colleges of Optometry-India CommonMinimum Optometry Curriculum (CMOC) for India. http://www.asco-india.org/Content/Downloads.aspx?MLID=MA%3d%3d-mn0HrU3x07E%3d&MID=MA%3d%3d-mn0HrU3x07E%

3d&flag=Vg%3d%3d-8BxLXKnuqs0%3d (accessed on 4 January2016).

5. Anuradha N, Krishnakumar R. Role of optometry school in singleday large scale school vision testing. Oman J Ophthalmol 2015;8: 28–32.

6. Makgoba MW, Soni DV, Chetty D. Institutional outreach. http://www.ukzn.ac.za/publications/outreach2005.pdf (accessed on 4January 2016).

How to cite this article Anuradha N, KrishnaKumar R. Social accountability in optometric education, Sci J Med & VisRes Foun 2016;XXXIV:7–10.


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https://ctools.umich.edu/access/content/group/1106364909396-12033726/Sandmann_L_FulfillHighEdCovenant.pdf





http://www.asco-india.org/Content/Downloads.aspx?MLID=MA&percnt;3d&percnt;3d-mn0HrU3x07E&percnt;3d&MID=MA&percnt;3d&percnt;3d-mn0HrU3x07E&percnt;3d&flag=Vg&percnt;3d&percnt;3d-8BxLXKnuqs0&percnt;3d









http://www.ukzn.ac.za/publications/outreach2005.pdf



Innovations in Optometric Education

A. Rashima and R. Krishnakumar

If you want something new, you have to stopdoing something old — Peter F. Drucker

Innovations start with creativity. Imagining newthings and exploring the ideas into the real world.Education system, being creative, has exploredinto many paths and now has taken this stage ofvirtual learning. In this article, we will see thepaths taken by optometric education.

OPTOMETRY AND COMPETENCYWorld Council of Optometry defines Optometryas a healthcare profession that is autonomous,educated, and regulated (licensed/registered)and optometrists are the primary healthcarepractitioners of the eye and visual system whoprovide comprehensive eye and vision care,which includes refraction and dispensing,detection/diagnosis and management of diseasein the eye and the rehabilitation of conditionsof the visual system.1

Schools and colleges of optometry train the stu-dents to achieve this goal. The common minimumoptometry curriculum intends to build the coursein such a way that the outgoing optometrists arewell equipped for clinical care, specialty care,diagnostics and community eye care.2 The educa-tion system revolves around the curriculum. In the4 years of optometric education at the under-graduate stage, the curriculum is built in such away that the training makes the student to evolveas an equipped optometrist. The conventionalmethod of teaching is prevailing in many schoolsand colleges of optometry which is evolved in19th century. Though there are many techno-logical innovations and fast forward computa-tional skills, optometry still in schools are thoughtin traditional way. New innovative models ofteaching methods are adopted in few institutes.

CONVENTIONAL METHOD OF TEACHING ANDASSESSMENTThe conventional mode of teaching includesdidactic lectures, presentations, practical sessionsetc. With these methods students have to followthe teaching notes of the lecturers and write theexaminations. In this way they do not link theconnections between the clinical skills and basicscience.

In the conventional method of teaching, basicsciences are taught first followed by clinicalsciences. Students are not found to be applyingthe concepts of basic science into their clinicalpractice. Traditional assessment of students con-sists of the yearly system of assessments.2 In most

institutions, assessments consist of internal andexternal assessments, and a theory examination atthe end of the year or semester. This basicallyassesses knowledge instead of assessing skills orcompetencies. This may not give us the holisticunderstanding about students’ knowledge. To fillthe gaps in conventional teaching and assessmentmethods innovative models were evolved.

Innovative models of teaching3

1. Vertical integrationIntegrating the clinical and basic science will

help the students understand the importance oflearning each process.4 By this method the knowl-edge and the skill are interlinked from the firstyear till they go in for independent practice ininternship. What, why and how? These are thequestions which are asked by the students at theentry of their curriculum. Thus each subject or theprocess is learnt with those questions. The curricu-lum has to be structured so that the link of sub-jects is done horizontally for each batch ofstudents and taken up throughout the years.

Vertical integration – our experienceVertical integration through student centred self-learning was initiated for the subjects of clinicalrefraction and binocular vision for the second-and third-year students, respectively. In this inte-grative model, basic science courses taught in thefirst year of the programme were revisited whileteaching applied sciences of clinical refraction andbinocular vision. Students were briefed about themethod of self-learning. Three of the five modulesof clinical refraction, namely Basics of refractiveerror II (integrating visual optics + instrumenta-tion), Classification and clinical examination ofrefractive error (visual optics + clinical examin-ation of visual system) and Management ofrefractive error I (visual optics + optometric optics+ dispensing optics)] and three modules ofBinocular Vision which includes Esotropia,Exotropia and Incomitant deviations (integratinganatomy, physiology, clinical examination, clinicalrefraction, epidemiology, primary eye care, pediat-ric optometry and pharmacology) were donethrough vertical integration. The components ofeach module were clinical scenario, learningobjectives, proficiency related to the objectives,study material and trigger questions. Studentswere grouped and faculty facilitated the learning.Assessment was done at the completion of everymodule. The feedback from the students and the

Elite School of Optometry, Unitof Medical Research Foundation,8, GST Road, St Thomas Mount,Chennai - 600 016

Correspondence:A. RashimaElite School of Optometry,Unit of Medical ResearchFoundation, 8, GST Road,St Thomas Mount,Chennai - 600 016E-mail: [email protected]


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faculty were documented at the end of thesemester.

The faculty and student feedback were positivetowards this approach. Self-learning methodsshould be combined with conventional teachingmethods. Skill-level acquisition and case analysiswas faster and better compared to knowledge-levelusing this approach. Based on the faculty’s obser-vation, this method enhances the practical skillsof the student compared to traditional approach.

2. Basic Clinical Optometry Skill Training(BCOST)

Bed side learning is the concept used in medi-cine from early centuries.4 The trainees be alongwith the mentors in clinics and learn the techni-ques of examination. Such training starts at thelater stage of education, i.e. during third or finalyear, thus students lack confidence in performingthe skills. We evolved a model of teaching theskills before the knowledge is imparted to the stu-dents. This makes the students more competent inperforming the skills thus when they learn on thepurpose and indications for the skills their under-standing is like written on a rock which is goingto be there life long.

3. Problem-based learningOther than the knowledge and clinical training,

students also need analytical skills for assessingthe case. The students have to be more skilful inanalysing a case which makes the outcome morefruitful. This can be imparted by theproblem-based learning (PBL). PBL5 is a grouplearning environment that involves a radicalchange in the way students learn and the role thatacademic staff play in facilitating learning. In thistype, the case or a situation is given to the stu-dents and they discuss about it in a group. Thementors facilitate the discussion, thereby thelearning process and the analytical ability isincreased. At Deakin University, they have well-established PBL curriculum. They have mentionedthat in PBL, identifying the groups also play amajor role, as there is strong influence of behav-iour of one student on the other in the team.

Innovative models for assessment2,3,6

Assessment is traditionally done as written exam-ination or practical assessment on clinical skills.Several new methods and tools are now readilyaccessible, the use of which requires special train-ing. Some of these are given below:

• Objective Structured Clinical Examination(OSCE), Objective Structured PracticalExamination (OSPE), Objective StructuredLong Examination Record(OSLER)

These methods give the faculty the flexibil-ity of testing the knowledge skill and attitude

of the students towards any given scenario.This is usually a time-based evaluation. OSCEand OSPE are used these days in a number ofallied and healthcare courses, e.g. optometry,physiotherapy and radiography. It tests the per-formance and competence in communication,clinical examination and medical procedures/prescriptions. It uses observation check lists orrating scales for scoring to emphasize on fre-quent assessment of learning outcomes. Thisprovides a feedback to the students as wherethey lack and gives an opportunity forimprovement unlike the traditional method.This OSCE and OSPE can be used to assessclinical skills and also the knowledge anygiven process. For example, in case of subject-ive refraction, with OSCE the student has toperform the technique over a subject and inthe next station he has to respond to the ques-tions on subjective refraction. This gives thefaculty on the level of knowledge the studenthas on subjective refraction.

This process needs a lot of time and supportfrom the faculty members. The stations arefixed according to the number of students tobe assessed. The response station (KnowledgeAssessment) and the performance station (SkillAssessment) are planned and the equipment’sneeded for the stations are arranged wellahead. The faculty or the examiners are placedat each station with the checklist for that par-ticular station. This way the bias in eliminated.The OSCE and OSPE also have an advantage ofproviding the feedback to the students at theend of the assessment. The response stationanswers are also displayed to the students sothat they get to know the answers.

• Short case evaluationEvaluating the students with short clinical

scenario will help us know their analyticalability. The case can be given to students andassessment on the management process isdone. This gives the holistic approach on anytype of cases. For example, a case on presby-opia can be given to the student and the pro-cesses of providing addition lenses along withhis refraction skills are assessed. His ability torelate the visual demand and the need of thepatient can be assessed by this process.

• Rubrics-based assessmentA rubric7,8 is a ‘‘scoring tool that lays out

the expectations for an assignment.” “Rubricsgenerally have 4 parts: (1) description of thetask, (2) the scale to be used, (3) the dimen-sions of the task, and (4) the description ofeach dimension on the scale.” Establishedcompetency standards are used as performancecriteria and indicators are planned for studentsto know where they stand. This system gives


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the feedback and also provides information onthe gaps. The students know from the descrip-tors their goal and strive hard to achieve it.

• Case-based discussion (CBD)This is a part of theoretical and practical

assessment. Cases can be simulated and thestudents are asked to discuss about the cases.The faculty facilitate about the case andanalyse the thought process of the students.

• PortfolioCreating students portfolio is a new tech-

nique. All the students’ assessment and per-formance throughout the year is recorded andprovided to the student. This gives the track oftheir performance and also guides the facultyto know the level of training to be given tothat particular student.

WHAT NEXT?The above-mentioned techniques are practiced infew colleges and institutes. Now let us see theemerging trends in education to enhance theteaching and learning technique with the use oftechnology.

• Technology-based online learningThe use of learning management system in

the curriculum will help to facilitate the onlinelearning. Many on campus and also offcampus distance education programs take thecourse management system such as Moodle fortheir programs.9,10 These systems save timeand make the course materials available to thestudents for ready reference. The advantages ofthese online systems are the students need notcome to regular classroom sessions. They canfix time with the faculty members for anycontact sessions if needed. This gives moreflexibility to the students for their timemanagement.

• Blended learningBlended learning is a hybrid of online and

face-to-face teaching.3,11 The students get toaccess the online teaching modules and alsolecture by the faculty. This technology enhancesteaching and also increases interaction betweenfaculty and students. The online system providesthe platform for the students to learn on thetechniques or the course in a better way. Theycan access the material at any point of time.Goodwin et al. reported that blended learningallowed for more flexibility in that the studentscould do the assignments at any time of theday. It allowed more active student involvement.He also added that optometric faculty need tomeet the expectations of the students while deli-vering difficult material in an effective way.Thus there is a scope of blended learning to be

introduced in the curriculum for effective learn-ing process by the students.

• Evidence-based practiceThe process of evidence-based practice

(EBP) is based on the pre-requisite that clini-cians acquire, locate, evaluate and apply rele-vant high-quality medical information to aclinical question. EBP4,12 should comprise col-lection, interpretation and integration of validand applicable patient-oriented, clinician-controlled and research-derived knowledge(evidence). Still further, the best available evi-dence is “brushed up” by patient circumstancesand, in particular, preferences to be finallyapplied to improve the quality of clinicaldecision-making and facilitate cost-effectivecare.

• Simulators for clinical skillsSimulators can be of use in teaching the

clinical skills to the students. Instead of prac-tising on to each other, the simulator trainingwould be more beneficial. This has been aproven method in medicine on the surgicalskills. Father of Surgery Susrutha,13 theancient Indian physician, taught the surgicalskills to his students on various experimentalmodules, for instance, incision on vegetables(like watermelon, gourd, cucumber etc.),probing on worm eaten wood, and precedingpresent day workshops by more than 2600years. Thus simulators for teaching skills likeretinoscopy or fundus evaluation can enhancethe education.

ConclusionAs said in the beginning, let us come out of old tostart the new. Let us adopt the new modes ofteaching and with the lessons from the newmodes, create further innovative models. Thefaculty members of schools of optometry can ini-tiate the innovative models in their classes andmake learning process as an easy task to students.

REFERENCES1. http://www.worldoptometry.org/en/about-wco/

who-is-an-optometrist/ (accessed 27 January 2016).2. http://www.asco-india.org/download/CMOCFINAL.pdf (accessed

27 January 2016).3. Innovative teaching methods, Optometric Education. J Assoc

Schools Coll Opt 2013; 38 .4. Potomkova J, Mihal V, Zapletalova J, Subova D. Integration of

evidence-based practice in bedside teaching paediatricssupported by e-learning. Biomed Pap Med Fac Univ PalackyOlomouc Czech Repub 2010; 154(1): 83–88.

5. Krishnan S, Vale CM, Gabb R. Making PBL teams successful: astudy on student diversity in a first year electrical engineeringprogramme, In Proceedings of the 1st Research Symposium onProblem Based Learning, Aalborg, Denmark, European Societyfor Engineering Education, Aalborg, Denmark, 2008.


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http://www.worldoptometry.org/en/about-wco/who-is-an-optometrist/







http://www.asco-india.org/download/CMOCFINAL.pdf



6. Kiely PM, Horton P, Chakman J. The development ofcompetency-based assessment for the profession of optometry.Clin Exp Opt 1995: 78: 206–218.

7. Stevens DD, Levi AJ. Introduction to Rubrics: An Assessment Tool toSave Grading Time, Convey Effective Feedback and Promote StudentLearning, 1st edn. Sterling, VA: Stylus Publishing LLC; 2005.

8. Boateng BA, Bass LD, Blaszak RT, Farrar HC. The developmentof a competency-based assessment rubric to measure residentmilestones. Journal of graduate medical education, 2009; 1(1),45–48.

9. http://neco.mrooms.net/ (accessed 2 February 2016)10. http://moodle.city.ac.uk/course/index.php?categoryid=15

(accessed 2.2.16)11. Blended learning in optometric clinical procedures instruction.

Optometric education. J Assoc Schools Coll Opt 2014: 39(2).12. Downie LE, Keller PR. Pragmatic approach to the management

of dry eye disease: evidence into practice. Optom Vis Sci 2015;92 (epub ahead of print).

13. Saraf S, Parihar R. Sushruta: the first Plastic Surgeon in 600 B.C. T Internet J Plastic Surg 2006; 4(2).

How to cite this article Rashima A, Krishnakumar R. Innovations in Optometric Education, Sci J Med & Vis Res Foun2016;XXXIV:11–14.


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http://neco.mrooms.net/

http://neco.mrooms.net/

http://moodle.city.ac.uk/course/index.php?categoryid=15(accessed



Innovations and Advancements in Refractive errormeasurements

H. Sumeer Singh, K.S. Prahalad and A. Vijayalakshmi

IntroductionGlasses have been part and parcel of our life, be itsunglasses that we wear when we go to the beachor the power glasses which help us to read ourfavourite book, glasses overall have helped us tosee the world around us with great clarity and pre-cision. But I always wonder how people aroundthe world used to see before the advent of glasses.According to the tales and fables from the RomanEmpire, a Roman Tragedian born about 4 B.C. wasalleged to have read “all the books in Rome” bypeering at them through a glass globe of water.Around the same time Nero from the RomanEmpire used an emerald held before his eyes whenhe watched gladiators fight. The oldest lens wasmade of polished rock crystal and was used forburning holes in the parchment was found in theruins of ancient Nineveh. Over the centuries thatfollowed, glass lenses started being widely used asa form of correction for people facing difficulty inseeing and the world began to see differentdesigns of frames and lenses come into the trademarket.

In the late 19th century, Sir William Bowmannoted a peculiar linear fundus reflex through anophthalmoscope, and this finding eventuallyhelped Cuignet to come up with a method whichwas later known to the world as Retinoscopy. Thisled to a great revolution worldwide as peoplestarted practising retinoscopy to help provide thepatient with a more appropriate spectaclecorrection.

In the following sections we will look as tohow this concept of retinoscopy has taken form inthe machinery of the modern era.

AUTO REFRACTORSAfter the introduction of retinoscopy which pro-vided a starting point for the objective refraction,it was soon followed by an instrument called thePhoropter (or refractor). Where instead of placingthe lenses with our hands into the trial frame, thelenses automatically fell into place with the touchof a button. The additional time required tomanipulate trial lenses and their limitations inregards to binocular vision testing makes theirroutine use impractical in a busy practice.

In 1973, based on the principle of Scheiner’sdisk, an auto-focussing system based on patientfixation in the closed field was invented tomeasure objective refraction. It has been commonlyused and in a single click the measurements are

projected on the screen. Following this, in 1987,Canon came out with the Canon RK-1, which com-bined an Autokeratometer and an Autorefractor. Asthe closed field autorefractors had fixation targetinside the instrument, it was found to cause“Instrumental Myopia” which has been overcomeby the foundation of open field autorefractors(Figure 1). Open field autorefractors are currentlyused for research purposes, where natural fixationtargets are given and accommodation measure-ments can also be measured simultaneously.

SPOT VISION TESTERSThough autorefractors have found its way in theroutine clinical practice, its limitations in theassessment of pre-school children, has led to theinvention of hand-held vision tester and WelchAllyn spot vision tester is one such model(Figure 2) which is based on the principle ofphotorefraction. There are many such hand-helddevices and a few to mention would include

Figure 1:

Elite School of Optometry, Unitof Medical Research Foundation,8, G S T Road, St Thomas MountChennai - 600 016

Correspondence:H. Sumeer SinghEmail: [email protected]


Recent Advances

plus-optix mobile autorefractor and Nidek hand-held auto-refractor. These can be used in paediat-ric age group of 6 months and above. Spot visiontester is of lightweight, hand-held and easilytransportable with auditory alignment cues forobjectively determining refractive error at aworking distance of 40 cm. Refractive error assess-ment is done within seconds of capture time andthe information can be transferred through inbuiltWi-Fi connectivity. Apart from refractive errormeasurements, it also helps in determining bin-ocular vision anomalies (strabismus, anisometro-pia, etc.).

SMART PHONE AND ONLINE-BASED TESTINGWith the availability of inexpensive microproces-sors and development in technology, researchersfrom Massachusetts Institute of Technology devel-oped the world’s first smart phone-based diagnos-tic tool for human eyes known as NETRA. It isbased on the inverse principle of Shack–Hartmannwavefront sensor with a clip on device that can beattached to the cell phones. Here the patient isasked to manipulate patterns on the screen so thatthe he perceives only a single dot at the end(Figure 3). The number of clicks he takes to alignin each direction gives the complete spherical andcylindrical refraction parameters. Since the testingis completely patient dependent, it cannot be per-formed by individuals who cannot reliablyperform the task, such as young children and alsothe accuracy of the measurement is limited by thefocal length of the micro-lens array.

With improvement in technology and increasein use of gadgets, Aaron Dallek and Steven Leein 2012 founded the world’s first online eyeexam service “Opternative” to provide an optionfor healthy patients who may not require a yearlycheck-up but may still need a new prescription.Once registered in its website, a link is sent to thesmart phone and instructions are given in the formof audio. The examination takes about 25 min. An

ophthalmologist verifies the prescription and it isprovided digitally to the patients within 24 h.

ADJUSTABLE EYEWEARManual adjustable eyewear corrects differentrefractive errors using the same spectacle design.These lenses are built by sandwiching a layer ofoptical fluid between two lenses. By adjusting theamount of fluid between the two lens types, thecurvature of the lenses varies which in turnchanges the optical power of the lenses (Figure 4).The available ranges are +0.50DS to +4.50DS inhyperopic lenses and −1.00DS to −5.00DS in themyopic lenses. Electronic adjustable focus eye-glasses are the recent development of the adjustableglasses. These eyeglasses work by electronicallyaltering a thin layer of liquid crystal located insideeach lens, which then alters the corrective power ofthe lens. It can be made in more stylish form com-pared to the manual adjustable eyewear.

Figure 2:

Figure 3:

Figure 4:


Recent Advances

Through the years we see that although thebasic concept of retinoscopy and spectacle cor-rection have remained the same, the method ofobjective refraction has taken a huge step suchthat providing a person with the ideal glass pre-scription is no longer a tedious process and ithas been refined to the utmost level. Hence inthe years to come we can expect the process ofgetting a new pair of glasses would be as easyas getting a picture clicked on your phone.

References1. Drewry RD. What man devised that he might see. http://www.

teagleoptometry.com/history.htm (accessed 5 February 2016).2. Grosvenor T, Grosvenor TP. Primary Care Optometry. Elsevier

Health Sciences; 2007.3. www.welchallyn.com (accessed 5 January 2016).4. Pamplona VF, Mohan A, Oliveira MM, Raskar R. NETRA:

interactive display for estimating refractive errors and focalrange. In ACM SIGGRAPH 2010 papers (SIGGRAPH ’10),Hoppe H (ed.). Vol. 29, No. 4, New York: ACM Press; 2010, p77.

5. www.opternative.com (accessed 5 January 2016).6. www.focus-on-vision.org (accessed 5 January 2016).

How to cite this article Sumeer Singh H, Prahalad KS, Vijayalakshmi A. Innovations and Advancements in Refractiveerror measurements, Sci J Med & Vis Res Foun 2016;XXXIV:15–17.


Recent Advances

http://www.teagleoptometry.com/history.htm



http://www.welchallyn.com

http://www.opternative.com

http://www.focus-on-vision.org



Update on Spectacle Lens

S. Viswanathan

Majority of the advances in spectacle lens con-tinue to occur in the area of progressive lensdesign by most of the spectacle lens manufac-turers. Since the introduction of progressive add-ition lenses (PALs) in 1959 by Essilor, it hasgained worldwide acceptance for the treatment ofpresbyopia. While progressive lens design, manu-facturing and dispensing techniques have grownat a good pace in the last decade or so, recent pro-gress in “free-form” has made possible to fabricateprogressive lenses with much more precision. Inthis edition, optical designs of progressive lenseswith emphasis on “free-form” progressive lenses,occupational progressive lens, effects of harmfulblue-violet light will be reviewed.

INTRODUCTIONConventional bifocal has two distinct areas sepa-rated by a ledge. Due to this discontinuity, there isan abrupt change in image size and location,which is commonly referred as image jump, as theline of sight passes from distance into thesegment region. On the other hand, the lens powerin a progressive lens gradually increases from dis-tance to near (Figure 1), and is achieved byincreasing the radii of curvature in a progressivesurface. In the last two decades, the usage of pro-gressive lens has increased rapidly as develop-ments of progressive lens continue to dominateamong the researchers among lens manufacturers.

The distance zone has the distance prescriptionand the lower portion has the specified power forreading. These two are connected by a corridor of

progressive power that provides intermediate zone.Progressive lens provide desired add powerwithout any ledge in-between allowing wearers tofocus from distance to near without any disrup-tion. This is achieved by incorporating variousamounts of surface astigmatism in the lateralregion of the lens. So, for the wearer there is anarea of blur and distortion towards the periphery.So, this is one of the disadvantages of progressivelenses and the lens manufacturers have beenworking on this area to minimize the blur and dis-tortion. Earlier progressive lenses were primarilydivided into hard and soft based on the distribu-tion of power and surface astigmatism. In the harddesign, the blur and distortion in the peripherywas higher as the power progression was rapid. Inthe softer design, the unwanted astigmatismspreads across larger area of the lens surface,thereby reducing the overall peripheral blur. Thecurrent generation of progressive lens combinesthe advantages of both soft and hard lens. Alsoearlier progressive lenses were symmetrical wherethe lenses were rotated clockwise towards nasaldirection for each eye to obtain a clear near zone,whereas the modern progressive lenses are asym-metrical which ensures wider binocular fields ofview. Though the traditional progressive lensworks well for majority of the wearers, with theadvent of new gadgets the need for visual demandis constant changing. So, the one size or designmay not fit all progressive lens wearer.Fortunately, with free form technology, the manu-facturers are able to fabricate the desired designon a progressive surface.

Each prescription in free form is customizedbased on the wearer’s specifications to eliminateoptical aberrations such as surface astigmatism.1

As the power changes with each position of wear,it is important to consider the effects of vertexdistance, tilt of the lens, which may influence thefinal power of the lens. Fortunately, with the freeform technology all these factors are consideredwhile dispensing a progressive lens and a newcompensated prescription is provided. For pre-scription optimization, the wearer’s vertex dis-tance, pantoscopic tilt, face-form wrap, dominanteye and the preferred reading distance is consid-ered to improve the optical performance of a lens.Along with the above measurements, the behav-ioural pattern of the wearer is captured automatic-ally using some of the sophisticated devices asshown in Figure 2 and the information is trans-ferred to the processing lab. With increasingnumber of frame styles including the wrapFigure 1: Anatomy of a progressive lens

Correspondence:Mr S Viswanathan, HOD,Optometry and Optical Services,Medical Research Foundation,No 18, College road,Nungambakkam,Chennai - 600016Email: [email protected]


Update

around, where a complex atoric lens surface isneeded, application of free form technology isbecoming more relevant.1

One such lens is varilux® S series: 4D technol-ogy which incorporates all the above parametersmeasured using Visioffice® device to dispense acustomised prescription.

OCCUPATIONAL PROGRESSIVE LENSThe stress from the usage of computer or othergadgets especially at a closer distance may con-tribute to variety of symptoms which is collect-ively termed as “computer vision syndrome”.Occupational progressives are designed in such away that it reduces the strain of the wearers whileviewing at mid-range and near working distances.This is achieved by wider intermediate and nearzones, with a marked reduction in surface astig-matism at the expense of distance zone. Sincethese lenses have a wider intermediate and nearzone and little of distance zone, these lenses areusually prescribed along with progressive lenses asadd on lens for wearers whose needs are more forintermediate and near. These lenses are referred asdegressive lenses as the power from wider readingarea decreases from near to distance area.

PROTECTION AGAINST HARMFULBLUE-VIOLET LIGHTThere have been developments on coating oflenses to reduce the effects of harmful radiationsfrom blue-violet spectrum (415–465 nm) apartfrom UV radiation itself. Long-term exposure toblue-violet may affect the sensitive retinal cells

and lead to serious eye conditions like age-relatedmacular degeneration (AMD),2 leading cause ofvisual impairment in the western world.

To minimize the stress induced from the expos-ure of digital devices, Essilor tested three new add-itional refractive powers (+0.4, +0.6 and +0.85) on76 subjects, comprising (young adults aged 20—34years; pre-presbyopes aged 35–44 years and pres-byopes 45–50 years). 90% of the wearers havereported that the visual discomfort with digitaldevices has minimized with Eyezen lens alongwith Crizal prevencia.2

Driving lensZeiss has introduced a new lens, optimized fordrivers especially when driving on rainy days, andat night. This “Drivesafe” lens has a special anti-glare coating when driving in poor light condi-tions. This lens is available both in single visionand progressive lens category.

CONCLUSIONLatest advancements in progressive lens andcoating technology have further improved wearer’ssatisfaction. Progressive lenses will continue todominate the research among lens manufacturersas the visual demand is constantly increasing withincreasing exposure to digital devices.

REFERENCES1. Meister DJ, Fisher SW. Progress in the spectacle correction of

presbyopia. Part 2: modern progressive lens technologies. ClinExp Opt 2008; 91(3): 251–264.

2. http://www.crizalprevencia.com (accessed 4 February 2016).

How to cite this article Viswanathan S. Update on Spectacle Lens, Sci J Med & Vis Res Foun 2016;XXXIV:18–19.

Figure 2: Visioffice® (Courtesy: Optical Services, Sankara Nethralaya)


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http://www.crizalprevencia.com

http://www.crizalprevencia.com

Occupational Optometry Service – An Overview

R. Krishnakumar, A. Rashima and P.P. Santanam

INTRODUCTIONOccupational optometry service is the new discip-line of optometry in India. It was initiated as asubject in the undergraduate optometry pro-gramme for the first time in India in 1987 by DrP.P. Santanam, an eminent occupational healthprofessional at Elite School of Optometry. It gotinto exclusive clinical optometry practice in theyear 2012 when the first occupational optometryservices were initiated by Elite School ofOptometry/Sankara Nethralaya, a unit of Medicalresearch foundation.

WHAT IS OCCUPATIONAL OPTOMETRY?Occupational optometry is the branch of optometricpractice that is concerned with the efficient andsafe visual functioning of an individual at work.

ROLE OF OCCUPATIONAL OPTOMETRISTThe role of optometrists in occupational optometryservices includes primary eye care, eye safety con-sultation and vision consultation.

In our conventional service, anyone who isworking in an industry will go for eye examin-ation to either an optometry or ophthalmologyclinic. The limitation in this system is that most ofthe time the understanding of the visual demandand work environment of the person at work isnot taken into consideration in counselling orwhen optical prescriptions are given.

In Dr Santanam’s Text book of OccupationalOptometry, the role of the occupational optom-etrist is described as follows:

a) Diagnosis of visual deficiency and correctwhere necessary and possible.

b) Identify occupational causes of vision and eyeproblems. In indicated cases referral to the eyehospital.

c) To help establish the visual requirements orstandards for jobs.

d) Be able to advice on eye protection.

e) Visual Impairment assessment.

Vision Screening for the employees – prefer-ably using various occupational vision screenersavailable in the market. For example, Titmusvision screener, Keystone Vision Screener, EssilorErgomax.

Seven-step approachAn occupational optometry service includes thefollowing seven steps:

1. Visual Task analysis of different jobs inwork area

It aims at acquiring the information onvisual demand each job creates on the individ-ual; assess the need for the visual functionrequired for the job. This process of visual taskanalysis needs visit of the occupational optom-etrist to the work or job site/station to under-stand the process, therefore enhance theunderstanding of visual demand at work sitefor the individual. For example, to arrive at thevisual acuity demand for a job, it is essentialto measure the working distance between theindividual at work and the task, and theminimum size of the task itself. If the jobinvolves more of near working distance, theneed for the understanding the efficiency ofthe accommodation and convergence is criticalfor the job. If the job demands colour vision,for example in the dyeing industry, thenknowledge of the colours or the hues that areused in the work environment, will decide onthe colour vision demands of the individual atwork.

2. Determination of the visual capability anddefects of an individual

Based on the visual task analysis, thebattery of the visual functional tests that needto be done can be decided. These tests willhelp the optometrist in addition to routine eyeexamination to know the visual capability ofthe individuals at work and therefore knowabout whether they are visually competent;matching with the visual demand arrivedfrom the visual task analysis. This step willhelp the optometrist to plan the interventionrequired to achieve the goal of matching thevisual demand and the visual capability of theindividual – a step in fulfilling the ILO/WHOaim of occupational health.

3. Management and referralEffort will be taken to decide on the appro-

priate intervention in the form optical and/orprotective eyewear in this step based on theoutcome of the first two steps. The instruc-tions of usage and maintenance of the pro-tective eyewear should be given in this step. Ifthe individuals are found to have any ocularpathology, they should be referred to therespective specialized ophthalmologists.

4. Indoctrination and education of employeesAwareness on how to safeguard one’s eye

Elite School of Optometry, Unitof Medical Research Foundation,8, GST Road, St Thomas Mount,Chennai - 600 016

Correspondence:R. Krishnakumar, Principal,Elite School of Optometry,Unit of Medical ResearchFoundation, 8, GST Road,St Thomas Mount,Chennai - 600 016.Email: [email protected]


Major Review

sight in the work environment, advising onappropriate eye protection wear, the mainten-ance of the protective eyewear, appropriatereasons for which the protective eyewear needto be replaced or repaired, on the common eyediseases and the need for regular eyecheck-up are the essential components in thisstep.

5. Report to the employerA report about the visual demand in

various work- stations and the visual capabil-ity of the individuals in those work stationsshould be submitted to the employer. Thisreport should also carry information about therelevant recommendations which mightenhance the visual performance of the indivi-duals and therefore consequent improved prod-uctivity. For example, the ideal protective eyewear, appropriate lighting in the work environ-ment will be provided in the report.

6. Follow-upUsually the follow-up services need to be

provided to see the impact of the service pro-vided. This involves the visit to the workareas, interaction with the supervisors,employees and the employer.

7. Pre-placement evaluationIn addition to the above steps, optometrists

can contribute to the pre-placement and peri-odic medical examination of employees andgive input in case of compensationevaluation.

CASE STUDIESTannery industryOccupational optometry service was offered to atannery industry. Since most of the products sup-plied to the clients were rejected, the employerwas concerned about the mismatch of the originalcolour planned of the Tannery goods as againstthat was supplied. The occupational optometryteam visited the manufacturing set-up to under-stand the process and the environment. All theemployees were advised to undergo colour visiontest (Farnsworth Munsell 100 Hue test). The occu-pational optometrist suggested the employer, thepossibility of segregating the employees based ontheir ability to discriminate colours (Hues). Basedon the colour vision testing, the employees wereclassified into superior, average and low colourdiscrimination ability. The occupational optometryteam gave recommendation to match the peoplewith superior colour vision ability and the workwhich demands more of colour matching andcolour arrangement. In addition, the occupationaloptometrists also recommended the use of lightsource which do not distort the colour vision. Theemployer expressed satisfaction with the outcome

which helped him to resolve the problem of rejec-tion of the products.

Iron and steel industryOccupational optometry service in a sector of thislarge size was always challenging. The team ofoccupational optometrists visited the manufactur-ing set-up and understood the process involved insuch industry. Based on the observation and inter-actions with the occupational safety personneland the supervisor in various departments of theindustry, the departments were classified intovisual demanding and the visually hazardousdepartments. Visual task analysis was done to allthe visual demanding departments. The occupa-tional optometry team also discussed about theneed for appropriate safety eyewear amongemployees in the hazardous departments and forpeople who were exposed to chemicals about theneed for monitoring the colour vision to rule outneurotoxicity. The employer was provided withthe vision standards for different departmentswhich they can use for recruitment purposes andfor annual monitoring of the employees. In add-ition, occupational health centre was recom-mended to use vision screening device for theperiodical evaluation. A survey on visual symp-toms among the computer users of the industry,and awareness on visual hygiene were given. Adetailed report on our observations, findings andrecommendations was given to the employer.

Petrochemical refineryThe objective of the occupational optometryservice in the refinery was to know the visualfunction status of the employees who wereexposed to various organic solvents. FM 100 Huetest was done to the employees and relative dys-chromatopsia was calculated. In a controlledenvironment, the colour vision defect was notnoted. However, the recommendation was pro-vided to monitor the colour vision using appropri-ate colour vision tests. Instead of routine ishiharapseudoisochromatic test, the recommendation touse tests like D- 15 or FM 100 Hue was advisedduring periodic review.

ConclusionProper prescription of glasses and other visualinterventions enhances the visual ability, improvevisual comfort and enhances morale for betterproductivity – achievable through proper occupa-tional optometry services.

REFERENCES1. Santanam PP, Krishna Kumar R. Occupational optometry. In

Jayaraj G (ed.) Occupational Health Practice in Indian Industries.Chennai: Occupational Health Foundation. 2012; p546–551.

2. Santanam PP. Medical monitoring. In Santanam PP (ed.)Occupational Optometry, 1st edn. Chennai: Elite School ofOptometry, Unit of Medical Research Foundation. 2015; p77–84.


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3. Santanam PP. Lecture notes on occupational optometry.4. Krishna Kumar R. Visual task analysis. Santanam PP (ed.)

Occupational Optometry, 1st edn. Chennai: pnElite School ofOptometry, Unit of Medical Research Foundation. 2015; p39–52.

5. Monica R. Legislation. In Santanam PP (ed.) OccupationalOptometry, 1st edn. Chennai: Elite School of Optometry, Unit ofMedical Research Foundation. 2015; p123–136.

6. Anuradha N. Personal protective equipments. In Santanam PP (ed.)Occupational Optometry, 1st edn. Chennai: pnElite School ofOptometry, Unit of Medical Research Foundation. 2015; p263–293.

7. Krishna Kumar R Vision standards. In Santanam PP (ed.)Occupational Optometry, 1st edn. Chennai: Elite School ofOptometry, Unit of Medical Research Foundation. 2015;p53–70.

8. http://www.aoa.org/optometrists/occupational-vision-manual/part-1-introduction (accessed 21 July 2015).

9. Rashima A, Santanam PP. Visual impairment assessment. InSantanam PP (ed.) Occupational Optometry, 1st edn. Chennai:Elite School of Optometry, Unit of Medical Research Foundation.2015; p114–122.

How to cite this article Krishnakumar R, Rashima A, Santanam P.P. Occupational Optometry Service – An Overview,Sci J Med & Vis Res Foun 2016;XXXIV:20–22.


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http://www.aoa.org/optometrists/occupational-vision-manual/part-1-introduction







A Tale of Intermittent Exotropia and Amblyopia – DoesVision Therapy Help?

Jameel Rizwana Hussaindeen and T.S. Surendran

Among the types of exotropia in childhood, inter-mittent exotropia (IXT) has been reported to be themost common type. In a population-based cohort,1

the prevalence of exotropia has been reported to be1%, with convergence insufficiency and intermit-tent exotropia being the commonest of the sub-types. A recent large population-based cohort2 of5831 preschool children reports a prevalence of3.2% of intermittent exotropia, with the basic anddivergence excess being the most common of thesubtypes. In a long-term follow-up3 of 184 paediat-ric patients over 9 years, 3.6% of children resolved;and over a 20-year period, 52.8% of the subjectshad an increase in the angle of deviation by morethan 10 prism diopters.

In the management of IXT, surgery plays animportant role in subjects who tend to increase intheir angle of deviation and have associated visualand quality of life issues. The role of conservativemanagement options like vision therapy still remainsequivocal and no substantial evidence is available forthe same.

This case report emphasizes the role of visiontherapy in the management of intermittent exotro-pia. Ms. H.V. a 6-year-old female with a diagnosisof intermittent exotropia and amblyopia was suc-cessfully managed with vision therapy. The childimproved in aspects of both visual acuity andvisual efficiency.

HISTORYH.V., a 6-year-old female was brought by her motherwith complaints of intermittent outward deviationsince 2 years of agewith increased frequency and dif-ficulty in viewing far objects since the past 2–3months. There were no other specific complaints. Thechild had been advised to use eye glasses by the localoptometrist and was also advised to undergo ocularsurgery for strabismus by the local ophthalmologist.Birth history was insignificant except that the motherhad tuberculosis during the fourth month of preg-nancy and was on treatment for the same. The child’sdevelopmental milestones were normal and academicperformance was good. There was a family history ofexotropia in the maternal aunt. The child had notstarted to use any eyeglass prescription. The diagnos-tic data are provided in Table 1.

PROGNOSIS AND GOALSThis patient has amblyopia secondary to anisome-tropia and an added component of intermittentexotropia. Treatment of amblyopia and divergence

excess were sequenced with amblyopia therapyfirst. While in some cases refractive error correc-tion alone is considered to treat amblyopia, attimes additional treatment is required. Glasseswere prescribed based on the subjective accept-ance after the cycloplegic refraction and afollow-up visit was scheduled for 1 month. Thevisual acuity in the left eye improved to 20/50and the right eye visual acuity remained the same.The parent felt that the deviation was reducedwith glasses. Since the visual acuity did notimprove to 20/20 with refractive adaptation alone,part time patching of OD for 4 h/day with nearvisual activities was advised.

Based on the study regarding effectiveness ofrefractive correction alone by the PEDIG investi-gators,4 it has been reported that 75% of theirsample improved by two lines with only refractivecorrection over a 25-week follow-up. Our subjecthad amblyogenic risk factor of both strabismusand anisometropia and hence, patching wasinitiated after 4 weeks of refractive adaptation.The child returned for a follow-up examination 2months later and visual acuity improved to 20/25in the right eye and 20/30 in the left eye. Therefractive error remained stable when assessed atthis point of time. A trial of vision therapy wasdecided to be administered in discussion with theophthalmologist considering the age and thecontrol of deviation. The parent was explained theneed for surgical management in the absence ofimprovement in sensory and motor fusion withvision therapy. The general recommended therapysessions are between 24 and 36 visits as recom-mended by Scheiman and Wick (2008).5 Visiontherapy was initiated after the second follow-up.Binocular vision assessment was done at thebeginning of vision therapy and the relevantdetails are as listed below (Table 2).

The primary goal in the presence of normalretinal correspondence in Divergence excess is toeliminate suppression, train diplopia awareness,and to sequence fusional training, beginning fromthird-grade stereopsis to first-grade simultaneousmacular perception. Based on this approach, thefour general goals for vision therapy were to

1. Eliminate suppression, developing the aware-ness of physiological diplopia and develop-ment of third degree fusion

2. Incorporate techniques to train vergenceamplitudes and second degree fusion skills

Correspondence:Jameel Rizwana Hussaindeen,Head – Binocular Vision/VisionTherapy ClinicDoctoral researcher – SrimathiSundari SubramanianDepartment of VisualPsychophysics, Lecturer,Elite School of Optometry,Unit of Medical ResearchFoundation, 8, GST Road,St Thomas Mount,Chennai - 600 016.Email: [email protected]


Short Review

3. Develop first degree fusion skills and thedynamics of vergence

4. Train eye-hand coordination skills, accommo-dation and oculomotor skills (incorporatedduring every phase of the vision therapy)along with the other training.

The sequential phases of therapy used for thesepatients include

1. Refractive adaptation for distance

2. Anti-suppression training for amblyopia com-bined with Monocular accommodation, fix-ation and ocular motility training

3. Gross vergence and training to appreciatephysiological diplopia

4. Smooth and Jump vergence training

5. Binocular accommodation training

6. Integration of procedures

The details of vision therapy provided in phase1 are given below.

Phase 1 (20 sittings over a month period)

– Anti-suppression training with red-green barreader

– Cheiroscopic tracings

– Pen light and red filter along with prismdissociation

– Computer Orthoptics (Anti-suppression andvergence)

– Brock string

– Accommodative rock therapy (Monocular andbinocular)

Table 1: Visual efficiency testing at baseline

Diagnostic data Findings

Uncorrected visual acuity (with Snellenchart)

OD: 20/40, Near: 6/6 at reading range 20–45 cmOS: 20/200, N6/6 at reading range 20–30 cm

Dry refraction OD: −0.50 DSOS: −3.50 DS/− 3.50 DC X180

Cycloplegic refraction OD: −0.50 DS/− 1.00 DC X180OS: −3.00 DS/− 3.00 DC X180

Subjective acceptance OD: −0.50 DS/− 1.00 DC X180 (20/30)OS: −3.00 DS/− 3.00 DC X180 (20/60)Binocular visual acuity −20/30

MEM retinoscopy OD: +0.50 DS OS: +0.75 DS

Ocular motility (ductions and versions) Full and free (OU)

Stereopsis Unable to appreciate using random dot stereopsis400 arc seconds (Wirt circles in Randot stereopsis)

Worth four dot test Fusion for near, and left suppression for distance (33 cm and 6 m) (inboth dark and ambient lit room)

Cover test Intermittent exotropia – left exotropia (IXT) for distance and nearBreaks spontaneously for distance; poor control for distance.New Castle Score: 4/9 (Home control + Clinic control)

Alternate Prism Cover Test 40 Δbase In for distance

(APCT) 25 Δbase in for nearPatch test: S/O True divergence excess (since the distanceangles remained the same and near angles increased by only 5prisms)

APCT with cycloplegic prescription intrial frame

30 Δbase in for distance15 Δbase in for near

Fixation (with accommodative target) Central, Steady and maintained for distance and near (OD)Central, steady and unmaintained for distance (OS); maintained fornear

Anterior segment and posteriorsegment examination

Within normal limits based on Slitlamp Bio-microscopy and IndirectOphthalmoscopy

Diagnosis Anisometropic amblyopia (OS)Intermittent left exotropiaTrue divergence excessAstigmatism (OU)Myopia (OU)


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– Home reinforcement opaque Life Saver cards,Eccentric Circles and Brock string

Follow-up:

– Visual acuity - 20/25 in OD and OS

After the first phase, review of findings sug-gested improvement in visual acuity, improvementin fusion and binocularity, no change in stereopsisand improvement in near positive fusional ver-gence. While the binocular visual acuity wasassessed, the child exhibited a small face turntowards the left and also occasional blur for dis-tance especially while performing distance fusionalvergence activities. Though the deviation was

comitant, the face turn could not be explained. Anover refraction did not reveal a change of refractionand dynamic retinoscopy revealed normal accom-modative response. Ocular motility was full andcover test was repeated with a −1.00 DS above thepatient’s glasses. The distance angles reduced by 8prisms diopters in primary gaze and for near thechild had an insignificant small exophoria. Withadaptation for about 30 min, the face turn almostdisappeared. Binocular visual acuity also improvedto 20/15 with the over minus lenses. The nearvisual acuity, amplitude of accommodation and theworking distance ranges were normal. The calcu-lated accommodative convergence/accommodation(AC/A) ratio is high in divergence excess due to the

Table 2. Visual efficiency assessment before vision therapy

Review after 2months

Visual acuity (with glasses)OD: 20/25, Near: 6/6 @20–45 cmOS: 20/30, Near: 6/6 @20–30 cm

Binocular Stereopsis: 500 arc sec (RDS targets); 30 arc sec (with circles)

vision assessment Worth four dot test: fusion for near and alternate suppression for distanceMEM retinoscopy: OD and OS: +0.50 DSNear point of convergence (NPC):With red filter and penlight: 25/30 cm (break/recovery)With accommodative target:Subjective & Objective: 15/20 cm (break/recovery)Amplitude of accommodation (AA) (push-up method):

– OD: 17 D OS: 17 D OU: 18 D

– NRA: +2.00 DS PRA: −2.00 DS

– APCT (with glasses): 30 ΔBI for distance and 15 Δ BI for near

– Gradient AC/A ratio: 7/1

– Calculated AC/A ratio: 10.4/ 1 (IPD: 55 mm)

– Binocular accommodative facility testing (+2.00/− 2.00 DS accommodative flipperswith N8 Word rock card): 7 cpm (difficulty with plus lenses)

– Vergence Facility Testing (12 BO/3 BI vergence flip prisms) at 40 cm: 6 cpm (Difficultywith BO prisms)

– Fusional vergence range (using RDS targets at 40 cm)

– PFV: 12Δ / 4 Δ(Break/ Recovery)

– NFV: 20Δ / 14Δ (Break/ Recovery)

– Saccades and Pursuits: Within Normal Limits

– Step vergence

– Blur Break Recovery

– NFV Distance X 10 4

– Near X 25 20

– PFV Distance 10 12 10

– Near 8 10 4

Diagnosis Divergence excessReduced PFV amplitudesReceded NPCReduced vergence facility


Short Review

difference in exodeviation between distance andnear, but the response AC/A ratio is typically foundto be normal. In IXT, when patients tend to usetheir excessive convergence accommodation in anattempt to converge that results in distance blur. Insuch cases, high convergence accommodation/con-vergence (CA/C) ratio is considered to be an indica-tor to prescribe minus lenses for distance.5 Thoughwe do not routinely measure this in the clinicalset-up, complaints of distance blur while trying tofuse is an indication of inability to inhibit accom-modation due to high CA/C ratio. Based on thesefactors, an over minus prescription of OD: −1.50DS/− 1.00 DC X180 OS: −4.00 DS/− 3.00 DC X180was given. The second phase of vision therapy wasinitiated with the new refractive correction.

The goals of second phase included

– Train second and third grade fusion at inter-mediate and far distance

– Train binocular accommodative and vergencefacility

– Train eye movements of saccades and pursuits

The details of vision therapy provided in phase 2is given below.

Phase 2 (15 sittings over a month period)

– Vergence therapy with major amblyoscope,Bernell O’Scope and Aperture rule

– Distance vergence training with computerizedvision therapy system (VTS4)

– Oculomotor skills (VTS4 and Pegboard)

– Brock string

– Accommodative rock therapy (Monocular andbinocular) using VTS 4

At the end of second phase of vision therapy,the angle of deviation for distance was well con-trolled (NCS – Control score 2/9) and reduced to20ΔBI (with the −1.00 DS over-minus prescrip-tion). The patient achieved desirable levels ofimprovement using the Aperture Rule, Bernell OScope, Variable Tranaglyphs (could work withmore central targets) and the VTS 4 system usingsecond-degree fusion targets. Vergence facilitystill remained poor and hence the next phasefocused on phasic training and vergence facility.Home reinforcement was prescribed at this stageand a follow-up after 6 months was advised.During follow-up, the vergence parameters andthe angle of deviation remained stable and thethird phase of vision therapy was initiated.

GOALS FOR THIRD PHASE OF VISIONTHERAPYMove from tonic to phasic training in vergence toemphasize vergence facility at all distance of training.

Phase 3 (10 sittings over a 2 weeks period)

– Jump vergence training (variable/ non-variableTranaglyphs/ Vectograms)

– Jump vergence training with VTS4, vergenceflippers and prism trainers

– Home reinforcement using computerized visiontherapy software, Distance large eccentriccircles

Follow-up (key parameters):

– Vergence Facility Testing: 10 cpm

– Step Vergence:

OUTCOME OF CASEThe distance angle was well controlled and otherparameters were consistent with the re-assessmentdone following the second- phase of vision therapy.The distance NFV was satisfactory, though notperfect. A cycloplegic refraction was done at the endof the final session which revealed OD: −1.75 DS/−1.00 DC X180 and OS: −4.25 DS/−3.00 DC X180.The child also preferred the new correction andchange of glasses were advised.

FOLLOW-UP CAREHome reinforcement was advised using the HTS,and free space fusion techniques (large eccentriccircles for distance, Brock string with vergenceand accommodative flippers) were prescribedduring the third phase. A re-assessment after 1month showed stable parameters and visualacuity. Need for constant reinforcement and thepossibility of a recurrence of the deviation ifvision therapy was abruptly stopped, wereexplained. At 1-year follow-up, the refractiveerror in the right eye had progressed to OD: −2.25DS/− 1.00 DC X180 and left eye remained stablewith no progression of myopia. Over a 3-yearfollow-up, there has been no specific visual symp-toms with stable parameters of ocular deviationand vergence.


Short Review

DISCUSSIONThis is an unusual presentation of intermittent XTin which the IXT was also associated with ani-sometropic amblyopia. The result was resolutionof the amblyopia along with a significantimprovement in the vergence parameters withgood control of angle of deviation.

The uniqueness of this case include the proto-col of vision therapy adopted for amblyopia andIXT customized based on the clinical parameters,and the long-term follow-up with successfulmaintenance of the achieved improvement. Thisopens up a new option in the conservative man-agement of IXT, when surgery is not indicated ornot attempted due to patient/ parental factors asin our case. Another uniqueness is the prescriptionof over-minus lenses to improve the control ofIXT for distance, based on the assumption that anelevated CA/C ratio caused distance blur and anassociated AHP to clear the image. As clinicalmeasurement of CA/C is complicated by the meas-urement protocol in itself, there are no guidelinesas to how much over-minus should be prescribed,and how long it should be prescribed. It could beargued that the over-minus resulted in the pro-gression of myopia, but there is no scientific basisto this argument. We consider that the progressionof myopia was coincident to the case, and notrelated to the over-minus prescription. Also therefractive error remained stable during thefollow-up periods. In the management of IXT, sur-gical correction has been recommended as astandard approach in patients with deterioratingcontrol and increase in the angle of deviation. Ina randomized controlled trial for IXT,6 that com-pared patching with observation of childrenbetween 3 and 10 years of age, both theapproaches have been reported to show compar-able outcomes in the deterioration of angle inchildren with previously untreated IXT. In youngerchildren between 12 and 35 months of age, parttime patching did not show any advantage overobservation on the control of angle of devi-ation.7 The angle of deviation and the controlscores remained stable in both the patching andobservation group over a 6-month follow-up inthis recent RCT.7 Systematic reviews reportingthe success of surgical outcomes point out to theabsence of lack of standardized outcomes toprove the efficacy of surgery over other treat-ment modalities.8 Orthoptic interventionthrough vision therapy has been recommendedas one of the conservative management optionsfor IXT by many authors.5,9 Some of the com-piled findings in a recent review suggests surgi-cal management combined with vision therapyas an appropriate option.9 All these findingspoint to the lacunae in the literature for standar-dized clinical trials proving the efficacy of thesetreatment options.

Vision therapy in the management of non-strabismic binocular vision anomalies like conver-gence insufficiency has gained increasing evi-dence in the past decade. Convergenceinsufficiency (CI) is a common binocular visionanomaly resulting in symptoms of eyestrain,blurred vision and asthenopic symptoms asso-ciated with near task. The convergence insuffi-ciency treatment trial (CITT) showed the efficacyof Office-based vision therapy as against conven-tional pencil push-up exercises and home-basedvision therapy in convergence insufficiency over a12-week period.10 Sustained improvements insigns and symptoms were reported in 73% ofstudy subjects. In this study, home-based pencilpush-ups was not efficacious in improving thesigns and symptoms and was comparable to theplacebo treatment. The mechanism of vergencetherapy in CI was established in a recent study,where apart from improvements in clinical signsand symptoms, the neural substrates using fMRIrevealed an increase in the percent signal changeof functional activity in the frontal eye fields, pos-terior parietal cortex and the cerebellar vermis.11

These results strengthen the role of vision therapyin the management of binocular vision anomalies,though there is scarce data specifically on visiontherapy for IXT.

Through this case report, we emphasize the roleof vision therapy as a conservative managementin the long-term follow-up of patients with IXT,for whom surgical management is not advocatedor postponed.

CONCLUSIONThis case report proposes vision therapy as a con-servative management option in the managementof intermittent exotropia. Vision therapy alsoplays a significant role in the amelioration ofpatients’ symptoms and improvement of binocularvision parameters.

REFERENCES1. Govindan M, Mohney BG, Diehl NN, Burke JP. Incidence and

types of childhood exotropia: a population-based study.Ophthalmology 2005; 112(1): 104–108.

2. Pan CW, Zhu H, Yu JJ, Ding H, Bai J, Chen J, Yu RB, Liu H.Epidemiology of Intermittent exotropia in preschool children inChina. Optom Vis Sci 2016; 93(1): 57–62.

3. Nusz KJ, Mohney BG, Diehl NN. The course of intermittentexotropia in a population-based cohort. Ophthalmology 2006;113(7): 1154–1158.

4. Pediatric Eye Disease Investigator Group. Treatment ofanisometropic amblyopia in children with refractive correction.Ophthalmology 2006; 113(6): 895–903.

5. Scheiman M, Wick B. Clinical Management of Binocular Vision:Heterophoric, Accommodative and Eye Movement Disorders, 3thedn. Philadelphia: Lippincott Williams & Wilkins; 2008.

6. Pediatric Eye Disease Investigator Group. A randomized trialcomparing part-time patching with observation for children 3 to10 years of age with intermittent exotropia. Ophthalmology2014; 121(12): 2299–2310.


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7. Pediatric Eye Disease Investigator Group. A randomized trialcomparing part-time patching with observation for intermittentexotropia in children 12 to 35 months of age. Ophthalmology2015; 122(8): 1718–1725.

8. Chiu AK, Din N, Ali N. Standardizing reported outcomes ofsurgery for intermittent exotropia—a systematic literaturereview. Strabismus 2014; 22(1): 32–36.

9. Lavrich JB. Intermittent exotropia: continued controversies andcurrent management. Curr Opin Ophthalmol 2015; 26(5):375–381.

10. Scheiman M, Kulp MT, Cotter S, Mitchell GL, Gallaway M,Boas M, Coulter R, Hopkins K, Tamkins S; ConvergenceInsufficiency Treatment Trial Study Group. Randomized clinicaltrial of treatments for symptomatic convergence insufficiency inchildren. Arch Ophthalmol 2008; 126: 1336–1349.

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How to cite this article Hussaindeen JR, Surendran TS. A Tale of Intermittent Exotropia and Amblyopia – Does VisionTherapy Help? Sci J Med & Vis Res Foun 2016;XXXIV:23–28.


Short Review

Year: 1985Aditya Goyal

Ananthalakshmi

Aruna Lath

Bhavani

Hitungshu Debnath

Janaki K

Jothi V S

Kandaswamy RR

Neena Asha Samuel

Padmaja

Radha K

Rama Devi Ravoor

Ritu Bajaj

Rukmani N

Saraswati B

Sathya M

Subha T

Keshav S Bhat

Vijayakumari

Year: 1986Aarti Anand

Anisha D Shah

Anitha A

Bhupesh Nagpaul

Chitra K

Deepa Rao

Manju H Chandak

Prema R V

Prithie Singh Rekhi

Priti C Chacha

Ramakrishnan V

Ramesh B

Sanjay H Mehta

Seeli Mathew

Shanthi Ananth Krishnan

Shyam Sundar

Singh R

Suresh V

Year: 1987Abdul Majid J

Ajay Kumar D Shinde

Akila A G

Amit Gupta

Gaurav Jaggi

Lakshmi K R

Meena K Joshi

Neena Chandrakanth

Premila Doss

Priya A S

Sajeesh Kumar K R

Snehal R Turakhia

Usha A Singhi

Yeshwant Vinayak Saoji

Year: 1988Bhavani S

Devakani R

Devi Priya J

Geetha V

Jayashree Vishwanath

Kaveri T.L.

Krishnakumar R

Prema K Chande

Sharmila S David

Soni K Radhika

Sowmya Ramesh

Tanuja C S

Vidya Shankar B

Year: 1989Anuja S

Kalikivayi Venkata Ramana

Kalpana K

Rajeev P

Sundaresan R G

S Viswanathan

Year: 1990Ananthalakshmi N

Arumugam S

Aruna Verma

Bubalan K

Chavan Nilesh Ganpat

Jehovahson C Isaacs

Neetha Mishra

Ramya D

A Sreelatha

Srihari N

V Srinivasa Rao

Year: 1991Bhavani Ramanathan

Bhuvaneswari R

Biswa Prakash Samal

Blessy Mary Oommen

Eunice Wilson

Ganesh K

Goldy George

Jayashree R

Lavanya M

Meera Mariam Jacob

Mohan Sundaram

Poongothai M

Pravesh Kumar Sahoo

Rakhi Sehgal

Rituraj Khanna

Saradha T S

Saraniya A S

Senthil Murugappa M

Shoba S

Veena R

Year: 1992Nandhini P Shah

Shobana S

Mahalakshmi R

Preethi A S

Ajitha G

Latha C

Shabeena Begum K

Ananth V S

Subhadra P

Radhika P

Kiran Kumari V

Veeramani S

Kavitha Vasudevan

Swapna S

Fareed Ali Dosani

Veshal Madan

Vandana Rajaram

Year: 1993Kamala Santanam

Jayaragini S

Vanitha P S

Sally Mary Abraham

Manovidhya B

Suren Kumar A

Premsudhakar L

Ajay Kumar V

Ashok Kumar Chendur

Aaesha Khatoon

Rathidevi Rajaram

Mhaske Balasaheb Dhansingh

Gare Rajesh Ramlal

Mhaske Prema Dhansingh

Khandelwal Amritraj Pannalal

Maneesha Varma

Year: 1994R Dharani

Brinda P

Mahalakshmi M

Nalini V R

Syed Nadeemullah

Ahalya Subramanian

Sumithra Mohanraj

Faiza Fathima

Sangeetha S

Anitha R

Rajaraman

N Anuradha

N Santana Lakshmi

Aparna Raghuram

Ganesh Babu T M

Anuja C M

Sandhya V

Sangeetha Pallavi

Kallakuri Sumasri

Ramkumar S

Rajeswari M

S Subhash

Srividhya H

Srinivas Abhiram Villupuru

Year: 1995Irene Sophia Joseph

Farzana Zia

Deepa C

Nidhi Ashwani

Shiney Sebastian

Jemima Oyan

Madhavan Renjini

Radha M

Manoj Subbaram V

Jayashree S

Indu V

Prema Raju

Varuna Padmanabhan

Sujatha G

PremNandhini S

Ramkumar R

Veena Adusumilli

Pinakin G

Swati Kulkarni Dinkar

Year: 1996Rajni R

Balamurali V

Vidhya S

Lakshmi T E

Subha T V

Valarmathi A

Chitra P

Shenbagam N

Sanjeev Rangan K

Krishna S

Humera Bulkis G

Maheswari S

Jaikishan

Venkataramanan

Hema R

Amudha Oli A

Aruna S Rajagopalan

Aman Anup Kumar

Mitalee Choudhury

Manoj Chandrakant Jadav

Year: 1997Sangeetha V

Kunal P Shah

Preetha Sampat

R Shivapriya

K T Ramprasat

Mehul K Gosalia

H Abrez

Elite School of Optometry (ESO): Undergraduate

(Continued)

Gitanjali Madan

Ravikanth Metlapally

Raiju Jacob Babu

Shrikant Rajangam Bharadwaj

Sowmya R

S. Ve. Ramesh

Richa Verma

Nithyalakshmi

Shankaran R

Bantu Sunil Kumar Sailoo

Jain Ujjwal Parasnath

Deepika T K

Year: 1998S Chitra

Rishi Bharadwaj

Girish kumar

S Vidhya

Gunjan kaushik

Padmasri R

Kishore kumar choudhury

N Sathyasri

Ratan kalita

Vidhyapriya S

Lakshman N S

Sruthi srinivasan

Baskar babu P T

Pancham kulkarni pramod

Deepa B M S

Abhijeet Saxena

Archana Bora

Revathy M

Arathy G

Wattamwar Raghavendra

Ramesh Rao

Year: 1999Tumpa Roy

Purabi Das

K Karthikeyan

Ushaa G

Premlatha J

R Kowsalya

N Mohana divya

Srijaya O V

Ramya C

Charanya R

Bijoy K Nair

Subam B S

Rahjee P

Suganya G

M M Preetha

Sowjanya G

A L Sivagami

V Bhuvaneswari

Tamilchudar Raju

M D Hemalatha

K Rajitha Reddy

Year: 2000Priya R

Annie Joseph

Sheth Jishnu Ashwinbhai

Vahini V

Linda Gomes

Radhika K

C.V. Sivaramakrishna

Padma Priya R

Karthikeyan B

Ambika M

Jameel Rizwana H

Ramya C

Saranya M

Ria Marian James D

N R Dhanya

Krithika Nandakumar

T. Preethi

Saritha Pillai

Ram Bahadur K C

G. Aparna

Lakshmi Kalita

L. Yamuna Devi

R. Kalpana

Aristotle Rabha

Ms Deepa Sonney Thachil

Year: 2001M Sasirega

K Archana

S Madhumathi

Archana Babu

P Kavithavalli

A Kannamma

M Anitha

J Salai Dhavamathi

Rashima A

Sonal Kaushik

S Jayasree

V Lokapavani

Rajalakshmi G

A R Saradha

Jitumoni Rajkumar

Anupam Deka

B Vijayalakshmi

Madhavendra B

Nabin Baral

Anupama

S Gayathri

Year: 2002Divya N

Premal M. Soni

Vandana G

Ujjwal Kumar Roy

M. Krithiga

J. Subha Priya

Lakshmi Priya R

P. Sridevi

Abinaya priya V

Kripa Nagarajan

Aiswaryah R

Sherin Mercy S

M. Jabeen

Palaniappan. L

Sindhu. C

Reehana Yasmin. I

Ayeswarya. R

K Spandhana

Ranjay Chakraborty

Year: 2003M Naganathan

Annapurani. K

Subhashini S

Nivedha S

Deepika vasudevan

Kalpa. N

Sreenagamugila M

Vijaya Anandan

S Farida

J Elango

S Kaleemunnisha

Kabilan P

Shonraj. B. G

R Siddhart Srivatsav

Sekar U

Malini V

Krithica S

Savita B. S

Sharavanan. G

Daksha G

K. Brindha

Rahul Chintamaneni

Arunkumar. K

Gayathri S

R Srilakshmi

Year: 2004E. Bhagyalakshmi

Yamuna devi G

Mahalakshmi R

Pavithra C

Vaishnavi O V

K R Swathi

G Sarika

Ashika Verghese

S Chandrashekar

Sailaja M V S

M.B. Aruna Janaki

Pavthra.K S

R. Revathy

N P Leelaa priaya

M. Sarasa

Manju J

R. Dhivyapriya

Sailakshmi.S

Mohana. K P

E. Julia Keren

D.R. Devi

Swapna Elizabeth Mathew

S. Aparna

H. Uma nandhini

Meenakshi S

S. Ramya

Anju susan Cherian

C. Sripradha

Aishwarya V

Year: 2005C. Vijayalakshmi

Sanjana K

Sheela Evangeline K

Ashwini M

D. Sandeep

Amritha. S

J Varadharajan

Sakunthala .P

M. Karthiga

Poornimadevi. S

Neenu rose Lawrence

Anshika Shah

Neelam kumari

B. Seetharaman

Kolisetty anusha

Abhinav maharwal

B. Vijayanadh reddy

Juthika talukdar

Divya S

Ayisha Atiya

Monica R

Sayantan biswas

Sheeba S

Raj kumar. N. R

M Jayasree

Year: 2006Deepom Sarah John

H Amitha Vikram Rugvedi

Indhushree. R

Bhargavi. J

Faresh V

M. Akila

S. Janani

G. Hemavathy

Shwetha. C.S

Revanth Kumar T

G. Mahalakshmi

Dheeraj Gupta

S. Veena

Shaj Shakila Banu s

Ramya D

Nandhini G

N. Yogalakshmi

Saranya S

Sri Devi. M

K. Manju Parkavi

Shraddha R

R. Sasikala

Lijo Ben Henry

Kowser Ilahin R Z

A.M.S. Hameeda Bibi

Silpa Mary Paul

Deepa K Vijayan

Sabarrish Srinivasan

Hiteswar Saikia

Year: 2007R. Nithya

M. Rahima Mumtaz

P Subramaniya Raj

V Srileka

S Karpagavalli

J Bhargavi

Farveena Saleem T

H. Praveen Singh

Malarvizhi M

D Dipthi Krishnan

Madhumitha S Mahadevan

G Jothi

Abhay D Shah

M Kavipriya

B Mahalakshmi

K Mahalakshmi

Pallavi Shaji

Leobin Francis

A Jayashree

B Manju

P B Archana

T Janani

Year: 2008P. S. Shobha

C Hemalatha

S Prerana

K Geetha

Sonal A. Vyas

M Bharani

J. Nivetha

A Essakimathy

Anjana Gopan

Dorcas W. Marbaniang

Najiya Sundus K M

Nigin C. Philipose

Pathan Jameer

T Suganthi

Year: 2009Aishwarya Sekar

Hashmath Sultana T

Vidyalakshmi J

Ashwini K

Mithra A

Sivasankari G

Swaathi B

Malini B

Swathi K

Shrilekha V

Bavithra K

Gopinath M

Nikhil N

Nayana Jose

Supraja K

K Meenakshi

Arishiya Kauser V T

Nadhiya Sultana A

A Kanimozhi

Yamini C

Sabiha Afroz U

Bhuvaneshwari G

Karpagam A

Karthick T G

Rekha S

Priyadarshini D

Janani S

Year: 2010Murugeshwari R

Krithika A

Jayapriya S

Jayalakshmi L

Jaikumar Jain M

Vasanth T M

Karthiga M

Nandhini R

Vaishaali G

Durgasri J

Geethanjalai G

Nihar N Davey

Varalakshmi K

Leenaa D

Greeshma G

Praveen Kumar P

Banumathi D

Pavithira A R

Girija M

Chitra S

Midhun P Mathew

Sumeer Singh H

Priya K

Rajesh N

Roopashree K

Riya Jose

Jayashree U

Abinaya M

Naveen Antony

Aishwarya M

Ashwini V C

Bijuna P Jose

Daleena Dalan

Rinu Thomas

Year: 2011P.A. Melba dhanamary

R. Santhiya

Nihama

Kousalya

A. Vennila

Maria Shaji

Jayashree K

T.M.A. Rehana khan

D. Asma Thabassum

Neethu sara mathew

R. Rupa

R. Hephziba blessy

J. EJeba cynthia

T. Nomitha baanu

S. Al. Ashra

S. Priyadharshini

R. Sujitha

P. Vasanthi

L. Kharthiyaa

Fathima Junaida. K M

Dhanya. S

R Jayashree

Madhumita

A.C. Sahana

A. Deepika

Post GraduatesJan 1996 – July 1999Dr. Krishnakumar R

Aug 1997 – July 1999Dr V S Ananth

Aug 1998 – July 2000Maneesha Varma

Aug 1999 – July 2001M Rajeswari

Ganesh Babu

S Syed Nademullah

S Subash

Aug 2000 – July 2002S Jayarajini

Aug 2001 – July 2003P Chitra

M Radha

Aug 2002 – July 2004S Ve Ramesh

B V Nithya Lakshmi

T K Deepika

H Abrez

Aug 2003 – July 2005Mitalee Choudhury

G Arathy

B M S Deepa

S Chitra

Aug 2004 – July 2006V Kiran Kumari

M M Preetha

B S Subam

Rahjee Perumal

R Kowsalya

Aug 2005 – July 2007A Valarmathi

R Padmasri

Bijoy K Nair

Aug 2006 – July 2008M Sasirega

A Amudha Oli

R Priya

S Sangeetha

Anton Decruse Wannbah

V Abinaya Priya

Aug 2007 – July 2009Gella Laxmi

H Jameel Rizwana

M Naganathan

G Muneeswar Gupta Nittala

Sekar U

S Krithica

V Lokapavani

R Rajni

A Rashima

G Sharavanan

B G Shonraj

Madhavendra Bhandari

P Kabilan

R Siddhart Srivatsav

S Kaleemunnisha

Aug 2008 – July 2010Brindha K

Arijit Chakraborty

Police Shailaja

Vandana G

S Aparna

Anju Susan Cherian(Continued)

Aug 2009 – July 2011M Revathy

Sayantan Biswas

Ayisha Atiya

Divya S

Leelaapriaya N P

Sheela Evangeline K

Ramya S

Damkondwar Deepali Ramesh

Monica R

G Aarthy

Aug 2010 – July 2012Priyanka Modi

S. Jaya Sowjanya

Sailaja M V S

Amritha S

Anshika Shah

Nandhini G

Jothi Balaji J

Aug 2011 – July 2013Deepom Sarah John

Mohana K P

Divya Jagadeesh A K

Ananya Datta

Deepmala Mazumdar

Ashraf Banu A

Asra Fatima

Aug 2012 – July 2014Dinesh V

Barsha

Indhushree R

Sheeba S

Prerana S

Ashim Dey

Aditya Chaitanya A

Aug 2013 – June 2015Pradipta Bhattacharya

N Srividya

Shenbagam N

Neeraj Kumar

Archayeeta Rakshit

Ann Mary Thomas

Najiya Sundus K.M

Doctorates from ESODr R Krishnakumar

Dr Dharani

Dr S Ve Ramesh

Dr Rajeswari M

COLLABORATORS➠ BITS, Pilani ➠ IIT, Madras➠ Anglia Ruskin University, UK ➠ SASTRA University, Tanjavur➠ Essilor International ➠ Transitions, India➠ Indiana University, USA ➠ University of Alabama, USA➠ University of Melbourne, Australia ➠ Linnaeus University, Sweden

MILESTONES of ESO

➠ 1985 – Birth of ESO at Sankara Nethralaya

➠ 1987 – ESO gets a new home at St Thomas Mount, Chennai

➠ 1994 – Affi liation to Birla Institute of Technology and Science, Pilani

➠ 1992 – First World Optometry Day celebration in India

➠ 1994 – Conducted fi rst All India workshop on Clinical refraction

➠ 1996 – Started M.Phil optometry degree program

➠ 1998 – Conducted fi rst National workshop on Ophthalmic dispensing

➠ 2001 – Conducted First international conference on low vision

➠ 2002 – First Dr. E Vaithilingam Memorial scientifi c session

➠ 2002 – Started Doctorate Programme in Optometry

➠ 2002 – Elite School of Optometry Alumni Association formed

➠ 2003 – Started Doctorate Programme in collaboration with Anglia Ruskin University

➠ 2005 – First Distance Learning Program in dispensing optics in collaboration with Silmo Essilor Trust

➠ 2005 – EIVOC – First international optometry conference in India commemorating 20 elite years of Optometric education

➠ 2007 – Award of fi rst PhD Optometry-India, from ESO

➠ 2008 – Campus named after Dr. V.G. Appukutty

➠ 2008 – ESO evolved and initiated fi rst meeting for Common Minimum Optometry Curriculum(CMOC) in the presence of Prof. Jay M Enoch

➠ 2008 – ESO aided The Palkhivala Foundation for the oration on “The need for Recognition, Regularization and Regulation of eye and vision care practices in India” by Prof Jay M Enoch, USA

➠ 2008 – ESO-SN Pediatric Optometry Fellowship was started

➠ 2008 – Smt. Sundari Subramanian Department of Visual Psychophysics Laboratory

➠ 2010 – EIVOC – International optometry conference in India with Specialty Optometry workshops by eminent professionals

➠ 2012 – Initiated Doctorate Programme in collaboration with SASTRA University, Thanjavur, India

➠ 2012 – LIMCA book of record for vision screening 8469 children in one day

➠ 2013 – Initiated fi rst Occupational Optometry Services in India

➠ 2013 – Signing of MoU with University of Alabama, USA

➠ 2013 – Awarding of Indo-US science and technology forum (IUSSTF) grant for exchange of clinical and research scholars

➠ 2015 – The 3rd ESO’s International vision science and Optometry conference EIVOC 2015

➠ 2015 – Signing of MoU with University of Melbourne, Australia

➠ 2015 – Signing of MoU with Linnaeus University, Sweden

➠ 2009–2015 – Screened 210550 people for vision problems

➠ 2015 – Screened 54000 children under the Titan happy Eyes in a record time of 15 days

➠ 2016 – Endeavour Fellowship for two faculty members for training at University of Melbourne

Pillars of Elite School of Optometry (ESO)

FoundersDr S S Badrinath, Prof S R Govindarajan, Prof Jay M Enoch

PatronsDr T S Surendran, Dr K Ravishankar

Principals of ESODr P P Santanam (1987–1991)Dr E Vaithilingam (1991–2001)Dr (Maj.) S Srinivasan (2001–2003)Dr R Krishnakumar (2003– present)

Administrative executivesMr T S Thiagarajan, Mr Rajan, Mr Panth, Mr Velayudhan, Ms Padma, Ms Uma Paramesh

LibrarianMs Geetha, Ms Nirmala Krishnan, Ms Jayasri

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