R Venkataramanan

R Venkataramanan

R Venkat's Blog

R Venkat's Blog
"To be an Inspiring Teacher,one should be a Disciplined Student throughout Life" - Venkataramanan Ramasethu



Sunday, September 22, 2013

The Medical and Vision Research Foundations celebrate 25 glorious years of knowledge sharing

It was a day of great fulfillment, a day to look back with pride and a sense of achievement for an institution with a deep faith and commitment in the acquisition and dissemination of knowledge, an institution with the firm belief that knowledge empowers and knowledge shall only be used for the common good. The Medical and Vision Research foundations celebrated the 25th Convocation day of their educational arms, the Elite School of Optometry, the Vidyasagar Institute of Bio-Medical sciences and the CU Shah Ophthalmic Post Graduate Training center, on the 18th of September 2013 at the Chinmaya Heritage centre on Harrington road, with justifiable pride and great passion. The day’s proceedings started at the packed to capacity ‘Tapovan Hall’ with the colourful pageantry of a ceremonial procession of the graduating students accompanied by the distinguished Chief Guest Dr S. Ravi Kumar, Dean, JIPMER, Pondicherry, Dr SS.Badrinath, Chairman Emeritus, Dr TS.Surendran, Vice-Chairman, Sankara Nethralaya, the Heads of the various Departments of the Vision Research Laboratory, Senior Consultants and distinguished guests in their colourful graduation gowns, truly a moment to freeze and cherish for the proud graduating students.

Dr SS.Badrinath, Chairman Emeritus, Sankara Nethralaya extended a warm welcome to the honourable Chief Guest, special invitees Dr. Vidyasagar Dharmapuri, Dr. Nagamani Vidyasagar and Dr Joe Benjamin, the esteemed dignitaries on the stage and the entire gathering. He had a special word of praise for the Chief guest Dr S.Ravi Kumar, Dean, JIPMER who chose to serve his home land, turning down lucrative offers in the West, underlining that the need of the day was highly qualified, high caliber, service minded individuals like him who would lead the country to great heights. He had a word of thanks to Industrialist and philanthropist Shri CK Shah to whose benevolence the Elite School of Optometry largely owed its existence. Dr SS.Badrinath highlighted that Education and training had been key areas of the Sankara Nethralaya ever since its inception and the educational instititons of Sankara Nethralaya were strongly committed to character building and grooming good citizens as much as producing subject matter experts.

Srimathi Anuradha Narayanan, Lecturer, Elite School of Optometry, set the tone of the day with a quote from Robert Frost’s timeless words on the need to go miles on one’s path of endeavour and Dr S.Meenakshi, Director, Academics, Sankara Nethralaya followed it up with a most interesting and inspiring account of Sankara Nethralaya’s 25 year journey on the road to education and learning and memorable milestones crossed along the way, from the foundation of the Elite School of Optometry by Professor Jay Enoch, Prof SR.Govindarajan and Dr SS.Badrinath in 1985 to the granting of prime land at St .Thomas Mount by Dr VG.Appukutty, she underlined that the ESO was a world class optometry institute with strong societal values and admitted students strictly only on merit. Dr S.Meenakshi credited the Vidyasagar Institute of Bio Medical Science with inspiring young minds and conducting high quality research in basic medical and fundamental science, and commended the role of the CU Shah institute in Post graduate studies in preparing a large number of students for their FRCS and Diplomate examinations.

Introducing the Chief Guest Dr Ronnie George, Director- Research, Vision Research Foundation observed that he was a man of outstanding academic and research excellence, has been rated as the best doctor in the USA several times, published more than 130 publications and hailed as the ‘Man to watch in the 21st century’ and it was a great honour to have him preside over the graduation ceremony. Delivering the Chief Guest’s address Dr S.Ravi Kumar congratulated the graduating students for reaping the fruit of their efforts from a superb institution run under the stewardship of a great visionary and world class ophthalmologists. He echoed Dr SS.Badrinath’s sentiments that while it was easy to expand the size and volume of an educational/Medicare institution the challenge was to maintain the same high quality while doing so and congratulated the ESO for winning in this challenge, congratulating the institution for going beyond is role of an optometry teaching and training center, to acting as vision ambassadors, through progressive measures like conducting free eye camps and for its pioneering role in placing Tamil Log mar/ visual acuity charts at vantage points in the city for the welfare of the common man. The chief guest strongly emphasized the need for health equity and justice and underlined that they were indispensable to sustain economic change and growth in the long run.

The graduation ceremony was also an occasion to honour and reward the masters who were responsible for the shining performance of the students as much as the graduating students and old associates, rich tributes were paid to the stalwarts and great teachers on the stage namely Prof PP.Santanam, Dr S.Ramaswamy, Prof Pichaimuthu, Prof.S.Veeraraghavan, Professor Sabiha N.Jameel and Professor Sumathi Narayanan who were being felicitated on the occassion. The occasion also marked the honouring of Dr HN.Madhavan, Director Microbiology department, Vision Research foundation and Dr G.Sundar Director, BITS, Pilani with the outstanding scientist awards and felicitation of Shri K.Ravi Shankar, the first Registrar of the ESO. The momentous function came to an end with a warm vote of thanks by Dr. J.Malathi, Reader, L &T Microbiology Department, Vision Research Foundation.

Wednesday, September 18, 2013

Sankara Nethralaya organizes a dinner for charity

In keeping with the current times and trend where ‘dinner diplomacy’ and ‘power luncheons’ seem to be making an impact, the Sankara Nethralaya senior management decided to reach out its message of eliminating blindness and emphasizing the need to support this noble initiative through a novel method of organizing Celebrity/Charity dinners. The dinner meeting would be an ideal get together for the invitees and also give them and their families the pleasure and thrill of interacting with a celebrity. The first of a series of charity dinners to be held on a monthly basis was held at the ‘Hotel Annalakshmi’ at Egmore, on the 31st of August 2013, with popular film star Shri Arvind Swamy as the celebrity guest of honour. The dinner get together was a great success as friends, supporters and well wishers responded warmly and turned up in good numbers. The invitees were thanked for their fine gesture of responding to Sankara Nethralaya’s invite and welcomed warmly by Dr SS.Badrinath, Chairman Emeritus, Sankara Nethralaya.

Addressing the invitees Dr Rajiv Raman, Senior Consultant, Department of Vitreo-Retinal Services gave a detailed account of the pipeline eye care projects at Chennai, namely the A.Sivasailam Block and the Community Hospital proposed to be built at the Appukutty campus at St.Thomas Mount and the ambitious healthcare, research and education facility coming up at Rajarhat, Kolkata and the financial outlay of these projects. The celebrity of the day who is also an old friend and strong supporter of the institution recalled with passion his late father, eminent industrialist Shri VD.Swamy’s long and close association with the institution right from the time of its inception and his memorable experiences during this time. He had a high word of praise for the high dedication levels of Dr SS.Badrinath, founder and Chairman Emeritus Sankara Nethralaya and the institution’s exemplary record in quality and service in eye care. He appealed to the gathering to support Sankara Nethralaya to enhance its reach for the welfare of mankind through its forthcoming projects and gave a good start to the effort by pledging his personal donation for a sum of rupees 2 lakhs. Shri NDJ. Renganath, a strong supporter of Sankara Nethralaya and a member of the board, Medical Research Foundation spoke on the starting of the Sri Srinivasa Sankara Nethralaya jointly by the Tirumala Tirupati Devasthanam and Sankara Nethralaya and its great service to the poor and indigent living around the area through its community eye care initiatives. Sri KS. Jayaraman, Director, Autolec Industries a regular and generous donor of Sankara Nethralaya rose to the occasion with a significant donation pledge and Shri Shishir Mundra son of SWAN member Srimathi Vimla Mundra made an on the spot donation towards the new projects.

The memorable get together came to a close with a warm note of thanks to the participants for their presence and continued support of the institution’s cause by Dr TS.Surendran, Vice-Chairman Sankara Nethralaya.

A knowledge based institution celebrates ‘Teacher’s day’ as a day of learning and good neighbourly spirit

As an institution with a strong emphasis in teaching and training, Sankara Nethralaya observed ‘Teacher’s Day’ as a day of knowledge acquisition, honouring a great teacher and good neighbourly spirit in the form of warm interaction with the members of the Madras Utkal association. The first part of the day’s celebration was marked by the delivery of in-depth lectures on the ‘Art of Communicating and Teaching’ and ‘Challenges in Medical Sciences’ by Dr KP.Misra, Director, Medical Education and Training, Apollo Hospitals, Bhubaneswar, a long time friend and associate of Dr SS.Badrinath, Chairman Emeritus, Sankara Nethralaya. This was followed by the delivery of the ‘Dr KP.Misra Endowment Oration’ by Prof Manoj Das a world renowned writer, outstanding orator in English and Oriya and a man of great learning and knowledge. Speaking on the topic ‘Vision of Future in Indian Mythology,’ Prof Manoj Das observed that we are passing through an age of paradoxes, an age where work is getting done at great speed, but we are left with no time to spare, we build elegant houses but live in broken homes, have advanced gadgets but continue to live in a state of confusion. He observed that Indian mythology if properly understood was highly reassuring and had the key to many of our problems, he rued that Hinduism as a religion, Hindu mythology and its symbolisms have been grossly misinterpreted and went on to give an in-depth interpretation of Shiva –Eternity and concepts like Timelessness, Atma, Brahma etc. He highlighted that Lord Jaganath was a personification of education and trust.

Speaking on the occasion Dr SS.Badrinath an old patron of the Madras Utkal Association and good friend of Dr KP.Misra, recalled with pleasure his humble role in founding the Dr KP.Misra Endowment Lecture in honour of a multifaceted and humanitarian doctor from Orissa who made Chennai his home away from home and served its citizens with passion and skill for 25 years. The highly enlightening function came to an end with a vote of thanks by eminent educationist and editor of well known spiritual journal Tatvaloka, Srimathi Sarla Panchapakesan.

Sankara Nethralaya celebrates 35 years of glorious service with a sincere salute to its friends and supporters

Sankara Nethralaya observed its 35th Foundation Day, Sankara Ratna award ceremony and the newly instituted Bharath Ratna Srimathi M.S Subbulakshmi award ceremony at the Sri VD Swami Auditorium, Sankara Nethralaya Main campus on September 6th, 2013. Extending a warm welcome to the Chief guest, His Excellency Shri K.Rosaiah, the Honourable Governor of Tamil Nadu, Senior Management members, employees of Sankara Nethralaya, winners of the awards, well wishers, supporters and members of the Press, Dr. Sripriya Krishnamurthy, In-Charge, Jaslok Community Ophthalmic Center (JCOC) highlighted that the ‘Temple of the Eye’ as Sankara Nethralaya was popularly referred to is the vision and will of one man Dr SS.Badrinath and the day marked 35 years of ethics, integrity and hard work which had made the institution what it is today. She observed that it was most appropriate that Shri K.Rosaiah a man who was known for his strict fiscal discipline and pioneering health schemes was presiding over the foundation day of an institution which was strongly committed to these values. She closed her welcome address with the observation that with greater recognition and growth comes greater responsibility, which every member of the Sankara Nethralaya family should be ready to shoulder. This was followed by an interesting introduction of Shri M.S.Jayaraman and Dr T.V. Subramanian the Sankara Ratna awardees by Dr Ronnie George, Director Research, Vision Research Foundation, he lauded them as the quality gurus responsible for taking Sankara Nethralaya’s quality initiatives in patient care, education and research to a new level and playing a critical role in Sankara Nethralaya being awarded the NABH (National Accreditation body for Hospitals and Health care providers) accreditation, the highest recognition for hospitals and health care providers, Dr Ronnie George declared with pride and gratitude that the herculean effort by the duo came Pro bono to Sankara Nethralaya, to the thunderous applause of the audience. Giving a warm and touching account on the contributions and sacrifice made for Sankara Nethralaya’s cause by Bharath Ratna Srimathi M.S.Subbulakshmi Award winners, Srimathi Kausalya Appukutty and Shri Manohar Devadas, Dr S.Meenakshi, Senior Consultant and Director, Academics, Sankara Nethralaya, observed that these individuals reflected the true spirit of Sankara Nethralaya and stood tall and noble offering themselves for a worthy cause in the midst of their own trials and tribulations, she added that institutions like Sankara Nethralaya made one feel proud to be an Indian.

A man who would never miss an opportunity to thank and honour the supporters without whom the institution could not have sustained and grown, Dr SS.Badrinath, Chairman Emeritus, Sankara Nethralaya expressed his deep gratitude to Shri R.S.Mehta and Shri Rajaratnam two strong and longtime supporters of Sankara Nethralaya for their huge contribution made recently to Sankara Nethralaya’s upcoming projects at Chennai and Kolkata. Acknowledging the honour of being awarded the ‘Sankara Ratna’ award on behalf of Shri M.S. Jayaraman and himself, Dr TV. Subramanian expressed that it was with a sense of utmost humility and gratitude that they were accepting these awards; he observed that they were most happy that their experience and expertise could be of purpose to a most noble and service oriented institution. The quality guru made a passionate appeal to the audience to think big, think positive and think creatively. He likened the 35 years of Sankara Nethralaya’s operation to a spiritual journey started by Dr SS.Badrinath, adding that while people may change and processes may undergo changes the crusade against blindness started by him would continue.

Extending a special welcome to the Honourable Chief Guest, Dr L.Vijaya, Director, Department of Glaucoma Services, Sankara Nethralaya observed that he would be always remembered for his adherence to fiscal discipline, strong resource mobilization and utilization capabilities and as the longest serving Finance Minister of Andhra Pradesh, she fondly recalled that Shri Rosaiah had inaugurated the Sri Sinivasa Sankara Nethralaya when he was serving as the Chief Minister of Andhra Pradesh. Delivering the Chief Guest’s address His Excellency Shri K.Rosaiah lauded that Sankara Nethralaya the ‘Temple of the Eye’ has given sight to many, he had a high word of praise to the high commitment levels of Dr SS.Badrinath and his team and Sankara Nethralaya’s role in community eye care and the technical advancements made by the institute in delivering quality eye care and taking it across to remote regions of the country.

The momentous function ended with a warm Vote of Thanks by Dr Geetha Iyer Krishnan, Consultant, Department of Cornea, Sankara Nethralaya.

Sankara Nethralaya conducts a lively and spirited awareness rally

The CU.Shah Eye Bank, Sankara Nethralaya, organized ‘Walk for Vision 2013’ a rally to create awareness on eye donation, as part of its eye donation fortnight celebrations. Spirited participants including Dr.T.S.Surendran, Vice-Chairman, Sankara Nethralaya, Consultants and employees of Sankara Nethralaya, staff members of Scope International a strong supporter and donor of Sankara Nethralaya’s community ophthalmology initiatives and members of the general public assembled in good number at the Labour Statue on the Marina, the starting point of the rally, well in advance of the scheduled time on the 7th of September 2013. The rally was flagged off by Srimathi Archana Ramasundaram, IPS, Director General of Police and Chairman, Tamil Nadu Uniformed Services Recruitment Board at 8:00am and veered its way along the Marina service road with enthused, slogan raising participants holding placards, banners and T-Shirt messages espousing the cause of eye donation, sending a clear message to the public at large.

The rally culminated at the Kannagi statue where the participants dispersed after a quick bite of sandwich and gulps of water. Dr. Niveditha Narayanan, Consultant, Cornea Department, and Sri S.V.G.Subramanian, Deputy Manager, CU Shah Eye Bank, Sankara Nethralaya briefed the press and media persons on the significance of the rally while Lion SN. Harinarayanan a member of the Lions Club of Central Madras and a strong supporter and friend of Sankara Nethralaya highlighted the need for awareness on eye donation and made an emphatic appeal to the media persons assembled at the venue to give good publicity and educate the public on this noble cause.

Prayers and holy invocation rituals mark the beginning of Sankara Nethralaya’s ambitious initiative

The Sankara Nethralaya family performed the ‘Sudarsana Homam’ the sacred Vedic ritual performed to appease the Gods and invoke their mercy and blessings on the 15th of September 2013 at its main campus, the ritual is performed every year to seek the Almighty’s blessings on the institution and for the all round well being of its employees, their family members and humanity at large. The proceedings started with the chanting of Vedic mantras invoking the Gods and seeking their mercy by Vedic scholars and priests at the specially erected venue at Sankara Nethralaya Main campus. The Sangalpam was received by Shri K.Venugopal, Commercial Controller, Sankara Nethralaya and his wife and the function ended with the distribution of Prasadam to all gathered.

This year’s Sudarsana Homam assumed special significance as it marked the auspicious beginning to an ambitious eye care project to be started just a street away at the old Lady Wellingdon complex. The specially erected Shamiana at the venue reverberated to the chanting of Vedic mantras and the air filled with the aroma of incense and smoke as the Sankara Nethralaya family led by Dr S.S.Badrinath, Chairman Emeritus, Dr. Vasanthi Badrinath, Director, Clinical Services, Dr T.S.Surendran, Vice-Chairman, Sankara Nethralaya, Shri R.Rajagopal, President Vision Research Foundation, respected members of the Medical Research Foundation, friends and supporters assembled for the ‘Bhoomi Puja’ of the Sri A.Sivasailam Block, named in memory and honour of one of Sankara Nethralaya’s earliest supporters, the illustrious former Chairman of the Amalgamations Group, South India’s leading Industrial House. The guests of Honour and lead donor of the facility Srimathi Mallika Srinivasan, CEO, TAFE, daughter of Shri A.Sivasailam, accompanied by her husband well known Captain of Industry Shri Venu Srinivasan and family graced the occasion and participated in the proceedings with great zest. Rendering of religious songs by Shri Sriram Kumar Ganesan, virtuoso violinist, Srimathi Akila Ganesan, Senor General Manager, Sankara Nethralaya and Dr S.Meenakshi, Senior Consultant and Director Academics to invoke the Almighty’s blessings on the new institution added soothing melody to the proceedings.

The highlight of the day’s function was the symbolic placing of the foundation bricks followed by sprinkling of holy water and grains by Dr S.S.Badrinath and Dr Vasanthi Badrinath, Dr TS.Surendran, Shri Venu Srinivasan and Srimathi Mallika Srinivasan, Shri R.Ramkumar, Managing Partner of M/S KS. Venkatraman & Co the civil contractors to the project and esteemed board members of the Medical Research Foundation. The continuous circling of a Kite or ‘Garudan’ believed to be an auspicious sign, in the clear blue sky over the venue of the homam right from the beginning of the proceedings, came as a great joy and hope to those in the gathering who believe in good omen.

The momentous function marking yet another milestone in Sankara Nethralaya’s progress, growth and service to humanity culminated with the throwing open of the foundation plaque announcing the name of the block, by Srimathi Mallika Srinivasan to the thundering applause of the gathering and distribution of prasadam to all assembled.

Tuesday, September 10, 2013

Teacher's Day Celebration @ SNK 2013 - OPTOMETRY DEPARTMENT

An ardent supporter and friend of Sankara Nethralaya wins coveted literary award from the Central government

Shri Mahadevan Iravatham an old friend and supporter of Sankara Nethralaya and the Founder of the Vidyasagar Institute of Bio-Medical Sciences, who is also a well known Tamil scholar, has been selected for the prestigious 'Tholkappiar Award' instituted by the Central Institute for Classical Tamil which comes under the Union Ministry of Human Resources.


The second of the series of workshops on best contact lens practice titled ‘Specialty Contact lens fitting’ held on 1 sep 2013 at the Sri.V.D.Swami Auditorium, drew over 50 odd enthusiastic participants that included senior Optometrists who graduated from the 2nd batch of Elite School of Optometry and private practitioners from all over India.

Welcoming the participants to the session, Dr.Rajeswari, In- charge, Contact Lens Clinic, detailed them on the objective of the session, which is to impart skillful practice of contact lens fitting in corneas that were variant due to pre/ post surgical procedures, irregular corneas, corneas that underwent degeneration or diseased !

A lecture on improving the quality of vision by eliminating distortion, ghost imaging by use of Soft Toric lenses for irregular corneas, presented by Ms.Sakunthala, Optometrist was well received. An account of the usage of conventional rigid gas permeable, its constraints were elaborated by Ms.Madhumathi, Senior Optometrist.

Ms.Amudha Oli, Senior Optometrist, highlighted the advantages of special design rigid gas permeable lenses over other types drew much attention. She explained that it was adherence of skillful contact lens practice that gave utmost comfort to the user held the key to success

Sri.Yeshwant Saoji, Optometrist, Saoji Vision care, Nagpur captivated the audience with his enthralling lecture on the viability of endearing practice of Specialty Contact lens in private set up.

Ms.Rajni, and Mr.Abdul Majid, senior optometrists elaborated on piggyback lens systems and Hybrid / specialized soft lenses for keratoconus. Dr.Rajeswari gave a detailed lecture on fitting and design PROSE lenses.

Case studies, real life examples demonstrating latest available lenses including the Piggy back, Rose K, Boston Scleral lenses and the video session on Fluoroscein pattern evaluation gave distinctive, hands on experience to the participants, who unanimously agreed, that such a workshop was unique of its kind.

The day concluded with distribution of certificates to the participants who expressed their utmost satisfaction on the session through their feedback

Dr SS.Badrinath becomes a celebrated doyen of his beloved city

The Ambassador group of Hotels, had as part of their ‘Madras Week’ celebrations selected seven leading personalities belonging to diverse fields through an independent jury consisting of eminent figures to be conferred with the title ‘Doyens of Madras’ for their significant contribution to their field of activity, their positive impact on the city and service to society through their chosen vocation and for doing their city proud. The awards were given away by the senior management members of the hotel at a function held on 30th August 2013 observed as ‘Madras Day’. The recipients spoke in length on the rich heritage of the city, its people, its pride of place and recalled their long and fond association with it.

Dr SS.Badrinath was honoured as a ‘Doyen of Madras’ for his role in rendering yeoman service to society, making quality eye care available to the rich and the poor, founding an exclusive eye care institution and nurturing it to world class standards, an institution which had over the years become a pride of the city. Delivering his acknowledgement and thanks note he remarked that he was born, brought up and educated in this great city and indeed most proud to belong to it and being conferred with the title ‘Doyen of Madras’. He recalled Sankara Nethralaya’s old association with the Ambassador Pallava, the excellent arrangements and hospitality by the hotel that he had experienced during official functions held there. Thanking the selection committee and the management of Ambassador Pallava for their gesture of conferring him with the title of ‘Doyen’, Dr SS.Badrinath made use of the opportunity to speak on the subject most close to his heart and had become the very purpose of his life, the need to create awareness on blindness, educating the people on its prevention and cure and to muster support for the battle against blindness.

Starting on a positive note he expressed that each and everyone assembled at the venue was a friend of Sankara Nethralaya and an Ambassador of its cause and they should resolve to do something for its cause of spreading awareness on prevention of blindness and its service to the indigent vision impaired. He explained that Cataract which was the most common cause of blindness, especially among the economically weaker sections was an easily reversible form of visual debility; he listed the causes for blindness as simple refractive error which could be treated by wearing a pair of glasses to diabetic retinopathy, glaucoma and retinoblastoma and how these could be prevented and treated. Dr SS.Badrinath briefed the audience on the community eye care initiatives being undertaken by Sankara Nethralaya, by way of the mobile glass dispensing unit, satellite aided tele-ophthalmology vans and the most advanced, first of its kind mobile surgical bus developed jointly with the IIT-Madras and the ambitious plans that Sankara Nethralaya had in the area of eye care especially to the underprivileged, he closed his thanks note with an emphatic appeal to the gathering to do something for their 10 million visually impaired countrymen.

Sankara Ratna & Smt M S Subbulakshmi Award 2013

Sankara Nethralaya's "WALK FOR VISION 2013"

Tuesday, September 3, 2013

Executing your Corporate Social Responsibility (CSR) with Sankara Nethralaya

The Government of India passes amended law on “Companies Bill 2011” making it mandatory for

1. Companies who have reported a net profit of 5 crores or more in the last 3 years to spend 2 percent of their profits on discharging their Corporate Social Responsibility

2. Companies with a market capitalization of more than 500 crores to spend 2 per cent of their annual net profits on discharging their Corporate Social Responsibility

 Sankara Nethralaya has been the preferred CSR partner of major Corporate entities like Indian Oil Corporation Ltd (IOCL), Chennai Petroleum Corporation Ltd (CPCL), Scope International (IT arm of Stanchart Bank), Union Bank of India and essilor to name a few, on account of the transparency of its community activities and the maximum deployment of allotted funds on the actual beneficiaries, with minimal overheads or administrative expenses.

 There could be little disagreement on the fact, that there cannot be a more painful handicap than blindness and no greater suffering than being confined to a world of darkness.

 Join hands with Sankara Nethralaya to fulfill in both word and spirit the above Government of India stipulation, by bringing Vision and a new ray of Hope and joy into the life of our lesser privileged, visually impaired countrymen.

For more information on executing your CSR with Sankara Nethralaya,

Please contact:


Mobile: 9383573811/9962282602

Email:alagiri@snmail.org, donation@snmail.org

Sunday, September 1, 2013

Low Vision Rehab Myths

Low Vision Rehab Myths

Seven primary myths regarding this specialty are costing patients and practitioners.

Sarah Hinkley, O.D., F.C.O.V.D., Big Rapids, Mich.

On the Discovery Channel series MythBusters, a team of science enthusiasts set out to test the validity of various Myths accepted as truth. For instance, it has been said that placing a silver spoon in an open champagne bottle will keep the sweet beverage bubbly. This and 424 other myths, out of 769—roughly 55%—have been “busted” since the shows debut nine years ago.

In informally asking fellow optometrists and former students, many of whom have completed residencies in low vision rehabilitation, why they don't provide low vision rehabilitation services, the answers I've received are saturated with common myths about this specialty.

Here, I list these myths, and in the words of the MythBusters team, I “bust” them.

1 “Plenty of O.D.s provide low vision services”

In fact, there are very few. Although exact estimates are difficult to obtain, in Michigan, an estimated 586,499 people in the 40+ age group alone have some type of visual impairment.1,2 Yet, of the approximately 1,600 optometrists, only 50 Michigan Optometric Association member optometrists say they provide low vision rehabilitation services.3,4 In speaking with low vision rehabilitation service providers in other states, they provide similar statistics. The consensus is that rural areas are the most underserved, probably because travel to metropolitan areas for care is often required and is largely complicated by the inability of these patients to drive themselves to appointments.

In addition, current low vision rehabilitation practitioner shortages are expected to worsen as the prevalence of age-related eye disease-causing visual impairment is estimated to double in the next three decades.5 In fact, between 1985 and 2050, the number of Americans 55 and older will increase by 113%, compared with a 33% increase in the general population, as estimated by the U.S. Census Bureau.6 This means there will be an even greater need in the foreseeable future for low vision rehabilitation services. Translation: There has never been a better time to expand your practice by providing low vision rehabilitation.

2 “Low Vision isn't stimulating”

I'll be the first to admit that learning and working with the necessary devices and lighting to provide low vision rehabilitation services is not always exciting, but this is only one aspect of the low vision rehabilitation practice. What many optometrists fail to remember is that patients who have visual impairment also have pathology. Therefore, those O.D.s who provide low vision rehabilitation are not sacrificing the excitement or challenge of ocular and systemic disease management. In actuality, these O.D.s are playing a crucial role in this management.

For example, if a diabetic retinopathy patient whom the low vision rehabilitation provider has been examining presents with a sudden change in visual acuity, contrast sensitivity, etc., it is under his or her jurisdiction to determine the reason(s), and this requires using various diagnostic tests to evaluate pathology. In fact, managing the vision rehabilitative needs of patients who have diabetes is one common example of the importance of the low vision rehabilitation optometrist on the patient's healthcare team.7

In addition, the opportunity arises for low vision rehabilitation providers to become involved in cutting-edge research through practice involvement or patient referrals for research trials.

The bottom line is that I have learned more about ocular and systemic disease in one month of low vision practice than in three years of primary care practice.

3 “I don't want to treat just geriatric patients”

The rising prevalence of agerelated eye diseases, such as agerelated macular degeneration, may lead some optometrists to erroneously think that low vision rehabilitation is solely comprised of geriatric patients. (See “The Senior Stereotype,” below.) However, visual impairment does not discriminate based on age.

For example, Stargardt's Disease alone affects 30,000 to 50,000 Americans and most commonly presents in the teenage years.8 In the University-based clinic at which I work, 51% of the vision rehabilitation clinic patients seen in the past year were younger than age 65.

In addition, connections the Vision Rehabilitation Service has made with local intermediate schools and teachers of the visually impaired have led to a growing patient base of children who have visual impairments. For instance, the fitting of bioptic telescopes, so teens who have visual impairments can gain or retain driving privileges, is becoming more common in the Eye Center.

So, if you think patient variety isn't possible with low vision rehabilitation, think again.

4 “Price is placed above functional improvement”

Although the examination and certain procedures can be coded medically, with rare exceptions, vision rehabilitation devices fall outside of both vision and medical insurance coverage.9,10 As a result, patients may opt out of purchasing a device that may benefit them. In my experience, however, I've found that the large majority of patients with vision impairment do purchase a recommended device regardless of whether their insurance covers it. The key to accomplishing this is to take the time to explain the specific benefit(s) of the device relative to the patient.

For instance, if a patient says she can no longer read to her children or grandchildren, she's likely to purchase a low vision device, such as a hand-held reader, if the low vision rehabilitation provider can show her how the device can enable her to revive this treasured pastime.

Something else to consider: For many, visual aids are a functional necessity, making a solution worth the price. For example, a patient who's unable to read his bills recognizes he'll lose his independence if he doesn't adhere to the recommendations of his practitioner.

Still not convinced? The Eye Center at which I work is located in a low socio-economic area. Yet, the average low vision rehabilitation patient spends approximately $260 per year on devices alone, and this doesn't include prescription spectacles, prisms or other dispensary-related items. For those patients who want to purchase a device, though can't afford it, we offer complimentary or low-cost used devices, payment plans, and we attempt to locate financial support from local or state organizations that serve the needs of patients who have visual impairments. It is our motto that no one goes without what they need, and yet our patient visits and device purchases have still produced strong financial dividends.

5 “It isn't profitable”

Low vision rehabilitation is feeling the same squeeze in medical reimbursements felt by other optometric areas. However, if billed correctly, this mode of practice remains profitable. Medical examinations can be billed multiple ways but are typically leveled based on the history components, such as the chief complaint and presence and extensiveness of the history of present illness, review of systems and past family and social history, the number of examination elements performed and medical decision-making.

The other option in medical billing is based on face-to-face time spent between the doctor and the patient. With regard to this, as long as at least half the face-to-face time is spent counseling the patient on such things as disease pathogenesis, progression, referrals to other professionals, orientation and mobility, safety, etc., you can bill based on time and obtain a nice reimbursement for the exam. To obtain reimbursement for low vision rehabilitation services, the 99000 or 92000 examination codes are typically used.

Keep in mind that examinations on patients who have visual impairments are commonly leveled higher than typical medical eye examinations for a number of reasons. These patients have complicated histories and disease. They very often need referrals to other healthcare providers, which you are coordinating. In addition, when billing is based on face-to-face time, the code level more accurately reflects the inordinate amount of patient counseling required to fully educate. So, even though a practitioner spends more time with each patient than in a typical examination, the higher coding levels reflect the time spent, resulting in higher compensation.

For instance, let's say you spend 60 minutes of face-to-face time with your new low vision rehabilitation patient, at least 31 minutes of which is counseling the patient. This examination would be correctly coded a 99205, reimbursing more than $200 in the metropolitan Detroit area.

Also, diagnostic tests, such as visual fields and ocular coherence tomography, are often necessary for management decisions. (Devices provide additional revenues, typically without the hassle or lag time involved in billing insurances.) And when performed, refractions and extended refractions are billed in addition to the comprehensive low vision rehabilitation examination. Something else to keep in mind: Utilizing a trained therapist may reduce doctor face-time and, depending on the credentials of the therapist or rehabilitation professional, be billable as device training or under the medical rehabilitation codes. More specific billing information, including required chart documentation, can be obtained through Medicare, other insurance carriers, college of optometry contacts or through other low vision rehabilitation providers.

In our clinic, the low vision rehabilitation clinic produces the highest per-patient revenue of any specialty area.

6 “Getting started is too expensive”

The need to purchase devices may at first appear overwhelming and costly. The reality is that with roughly $2,000, a practitioner can build an adequate device arsenal to get started. A supply of primarily low-powered illuminated and non-illuminated handheld and stand magnifiers, as well as low-powered telescopes is a great place to start. Assistance with the types of devices to purchase and their specifications can be obtained through device retailers or by contacting other low vision rehabilitation providers to get their input. Many state optometric associations have lists of these providers. I suggest membership in the American Optometric Association Vision Rehabilitation Section and the American Academy of Optometry Low Vision Section for direct connections with colleagues practicing in this area of optometry. (See “Resources for Developing a Low Vision Rehabilitation Practice,” below.) Many companies even offer pre-assembled starter kits, which may include an assortment of magnifiers, telescopes, microscopes or a combination. The manufacturers often loan the more expensive items, such as video magnifiers or portable electronic magnifiers, to optometry practices for a period of time at no cost or at reduced cost. This is because the companies appreciate practitioner growth in low vision rehabilitation and realize that doing this is mutually beneficial. Talking to a company salesperson or local sales representative is usually an effective way to inquire about loaner devices, as well as garner excellent practice management tips.

7 “It's not a core part of what we do”

Optometrists are rehabilitators. It is what we do. No other profession has the same understanding of functional vision. We are the primary eyecare profession that manages our patients from the cradle to the grave. Also, if it wasn't part of what we do, why would the curriculums in the colleges of optometry include course work and often labs on low vision rehabilitation? Further, why would optometric residencies and internships as well as conferences, online continuing education and workshops be available in this field?

Optometrists providing low vision rehabilitation services are typically part of an interdisciplinary team of professionals with unique skills and perspectives. The value of connectedness with other healthcare and rehabilitation professionals should not be underestimated.11 Optometrists could be viewed as the primary care physicians of the visual impairment world, coordinating and directing referrals to the appropriate sources. Serving as the kingpin in this type of healthcare network is a role optometry should embrace or risk losing.

Summing it up

The low vision provider connects patients who have visual impairments with the means to remain independent and the interventions that reactivate hope in the achievement of occupations, hobbies and activities of daily living. The aforementioned myths, viewed as fact by many in our profession, are preventing patients from improving their quality of life and optometrists from improving their bottom line. Hopefully, the busting of these myths will change this. OM

The Senior Stereotype
A very prevalent stereotype exists that seniors are difficult patients to please. My experiences and the experiences expressed by my low vision rehabilitation peers confirm that while challenging patients exist within any optometric specialty, our patients are overwhelmingly pleasant, loyal and appreciative. In fact, my geriatric patients tend to be the most grateful for the services I provide, as they confide that other doctors have treated them with a lack of dignity and respect.

Resources for Developing a Low Vision Rehabilitation Practice
American Optometric Association Vision Rehabilitation Section

American Academy of Optometry Low Vision Section

American Council of the Blind

American Foundation for the Blind

Council of Citizens with Low Vision International

Lighthouse International


National Association for Parents of Children with Visual Impairments

National Federation of the Blind

(1) Leonard, R. Statistics on Vision Impairment: A Resource Manual. Arlene R. Gordon Research Institute of Lighthouse International; 2002 April. 20 p.
(2) Lighthouse International. Prevalence of Visual Impairment. www.light house.org/research/statistics-on-visionimpairment/prevalence-of-vision-impairment. (Accessed Sept. 15, 2011)
(3) Michigan Optometric Association. Certification and Recertification. http://michigan.aoa.org/x10344.xml. (Accessed Sept. 19, 2011)
(4) LARA Michigan Board of Optometry. Department of Licensing and Regulatory Affairs. www.michigan.gov/mdch/0,1607,7-132-27417_27529_27546-59015--,00.html. (Accessed Sept. 20, 2011)
(5) Shoemaker, J. for Prevent Blindness America. Vision Problems in the U.S.: Prevalence of Adult Vision Impairment and Age-Related Eye Disease in America. 2008 www.preventblindness.org/sites/default/files/national/documents/vision-impairment-blindness.pdf. (Accessed Sept. 19, 2011)
(6) Brilliant, R. Essentials of Low Vision Practice. Boston: Butterworth-Heinemann; 1999. 7.
(7) Rosenberg, EA, Sperazza, LC. The Visually Impaired Patient. Am Fam Physician. 2008 May 15;77(10):1431-6.
(8) American Macular Degeneration Foundation. Stargardt Disease. www.macular.org/stargardts.html. (Accessed Sept. 20, 2011)
(9) Grover, LL. Strategy for developing an evidence-based transdisciplinary vision rehabilitation team approach to treating vision impairment. Optometry. 2008 April;79(4):178-88.
(10) Freeman, PB. Miles to go… Optometry. 2008 Nov;79(11):625-6.
(11) Stelmack, J. Emergence of a rehabilitation medicine model for low vision service delivery, policy, and funding. Optometry. 2005 May;76(5):318-26.

Dr. Hinkley is an assistant professor and chief of Vision Rehabilitation Services at Ferris State University's Michigan College of Optometry. E-mail her at SarahHinkley@ferris.edu, or send comments to optometricmanagement@gmail.com.

Optometric Management, Issue: October 2011

Low Vision and Depression

Mrs. R.M., an 86-year-old woman with macular degeneration, is brought to a low vision examination by her daughter. She is withdrawn, and has difficulty describing her recent eye care history. Her daughter reports that her mother has stopped going out with friends, and often seems fatigued. During the examination, Mrs. M. finds it hard to concentrate on the low vision devices being shown to her, and is unresponsive to any strategies suggested.

Depression and Vision Loss

Loss of visual function may be caused by eye conditions that affect the ability to read, see faces, or travel independently. This loss can be devastating because of its consequences. Some individuals may be in jeopardy of losing a job, while others may be forced to give up driving, which symbolizes independence and freedom of movement. Still others may be faced with the prospect of being unable to cope independently, and may have to move into a nursing home. It is not unusual for providers of low vision care to witness depression among their patients. According to the Mayo Clinic, many factors have been linked with depression, including: life changes, illness, medications, biochemical factors, history of mental or emotional disorders, and substance abuse. A heart attack, Parkinson's disease, stroke, or vision loss may lead to life changes that can cause depression. Individuals may exhibit the same emotional reactions to the loss of vision as those who lose a loved one or a limb. These reactions include: shock, depression, anxiety, disbelief, grief, denial or anger.

The person may also be affected by the recency of onset, severity, and suddenness of the loss of vision. They may experience a stage of shock where they refuse to think about the present situation, or they may appear unresponsive. This stage is often followed by depression. As the Mehrs state, an individual may then have feelings of hopelessness, lack of self-confidence, suicidal thoughts, self-recrimination, and psycho-motor retardation. As the person with low vision goes from doctor to doctor for the "magic" cure that will restore lost vision, only to be told that nothing further can be done, depression may intensity. "Many doctors, while dealing competently with diagnosis and treatment in the acute phase, are not aware of the patient's reaction to diminished sight", says Dr. Eleanor Faye, Clinical Advisor, Center Education, Lighthouse International.

Common Symptoms

Patients with vision loss may exhibit a response in any of the four basic psychological domains: emotional, cognitive, perceptual, and behavioral. Clinicians dealing with patients who have impaired vision should look for symptoms of depression that warrant treatment, including:

A persistent, pervasive depressed mood
Loss of interest or pleasure in usual activities
Increase or decrease in appetite or weight
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue or loss of energy
Feelings of worthlessness or excessive/inappropriate guilt
Impaired thinking or concentration
Recurrent thoughts of death: suicidal ideas, plans, and attempts
Clinicians working with patients exhibiting these symptoms should help to arrange an appointment with a psychiatrist or psychologist who understands the problems of vision impairment. Having a social worker on the multidisciplinary low vision team can enhance the capability to assess, counsel, or refer the person with depression and vision loss.

Vision Rehabilitation Can Help

Low vision care and other vision rehabilitation interventions can be important steps in the rehabilitation process. Mehr noted that depression could be overcome if tasks could be accomplished that the individual had seen as too difficult to do. Ellerbrock even suggested that mastering tasks, such as navigating to the bathroom alone or reading a letter with an optical device would help to overcome depression. Low vision devices, therefore, become an integral part of the process of regaining self-esteem, overcoming feelings of hopelessness, and regaining emotional strength as compensatory strategies are learned. An additional benefit of the low vision evaluation process, according to Dr. Faye, is the opportunity it affords "the understandably depressed person ... to ask questions about treatment, about the eye disease, and to express the frustration inherent in the experience of losing sight. Usually the realization that they can air their problems and that it's okay to talk about them gets the therapeutic ball rolling."

The Structured Low Vision Exam

The low vision examination has evolved from a series of independent procedures into a structured evaluation. Each part of the sequential examination provides the clues that will help in determination of the low vision device and provide insight into apparent success or lack of success with a low vision aid. The structured examination includes the current methods in the determination of visual acuity at distance and near with the ETDRS charts and functional testing techniques including the Amsler grid, contrast sensitivity testing, and the Brightness Acuity test. An understanding of the importance of the various components of the low vision evaluation will enable the examiner to prescribe the appropriate low vision device, including spectacles, hand magnifiers,stand magnifiers, telescopes, absorptive lenses, video-magnifiers, optical or nonoptical devices, or refer for other service or additional testing procedures.

The foundation for the present day low vision evaluation was set in 1935 by Dr. William Feinbloom in the monograph An Introduction to The Principles and Practice of Sub-normal Vision Correction. The elements of the subnormal vision evaluation or low vision evaluation, as it is known today, included a detailed case history, ophthalmometry, ophthalmoscopy, slit-lamp, visual field test, static retinoscopy, subjective examination at distance with "simple lenses," subjective examination at distance with sub-normal vision device, and subjective examination at near with subnormal vision device. A second visit was scheduled to establish the patient's prognosis, confirm the subjective and objective evaluation, and verify the objectives set forth in the case history. This was followed by selection of the optical device, training with the device, and prescription of the low vision aid. The monograph is also noteworthy in the discussion of the psychology of the low vision patient and the importance of illumination.

It took another 30 years before Dr. Gerald Fonda covered the basics of the low vision examination in The Management of the Patient with Subnormal Vision. He outlined the examination procedures as the history, testing of visual acuity at distance and near, retinoscopy, keratometry, subjective testing, and prescribing a reading prescription.

Dr. Eleanor E. Faye, however, was the first low vision clinician to discuss the importance of understanding the pathology during the low vision evaulation. In The Low Vision Patient, she discussed the basic eye conditions related to subnormal vision. She further underscored the relevance of the pathology to the management of the low vision patient with a functional classification of eye disease in Clinical Low Vision. And for the first time functional testing procedures, such as the Amsler grid, became part of the low vision evaluation.

The sequence of the low vision examination became further standardized in Low Vision Care by Dr. Edwin B. Mehr and Dr. Allan N. Freid. They were also instrumental in elaborating on the significance of the psychology of the low vision patient and the success-oriented examination. Other applicable additions to the low vision examination included color vision testing, response to illumination, and a systematic approach to near testing.

Dr. Jay Newman further clarified the low vision evaluation, while The New York Lighthouse Low Vision Continuing Education Program formalized, revised, and organized the structured low vision examination to what is essentially the accepted format of the low vision evaluation. A sequential low vision examination insures a higher rate for success as well as predicts difficulties encountered with the low vision patient.

Low Vision Basics

The basic low vision examination consists of the history, visual acuities, external evaluation, keratometry, subjective and objective evaluation, predicting the add, functional testing, selection of the appropriate low vision aid, instruction, and prescription or loan of the low vision aids.

The examination begins with a history which provides clues not only to the prescription of low vision devices but to any further services that may be required, such as medical counseling, mobility, rehabilitation and training, educational support, or surgical intervention. Among low vision clinicians there is a philosophical difference as to whether the case history should be taken before the low vision evaluation by means of a questionnaire sent home, by a social worker before the low vision evaluation, or on the day of the examination by the low vision clinician. Although a list of questions answered before the low vision examination may seem to expedite matters, it does not provide the answers to many questions that are obtained through direct observation or interaction with the patient. More importantly, face-to-face contact begins to establish a meaningful doctor patient patient doctor relationship. The patient may begin to relax and feel more confident in the fact that the doctor is taking the time out to listen to his or her complaints. Through the eye-to-eye contact, the patient often will realize that this doctor is interested in his or her vision problem.

At the outset it is usually best to let the patient relate the course of his or her visual changes, medical procedures, medications, surgeries, or their feelings without interruption (within a reasonable amount of time). This generally will relax the patient, lets them know you are interested in their visual history, and sets the tone for the examination. Because the majority of low vision patients are accompanied to the examination room by a friend or relative, it is also not unusual to obtain information from them when the patient is unresponsive or is sketchy about details. Conversely, the examiner must give the patient the chance to provide the answers, not the one who accompanied the patient. It also may be necessary to either ask the friend or relative to refrain from answering for the patient or on occasion ask them to take a seat in the waiting room. The examiner must be in full control so the examination can proceed in an orderly and time efficient manner.

The examiner then can structure and guide the patient into distinctive areas such as eye, medical, social, and educational history. Specific distance, near, and intermediate objectives, lighting needs, glare sensitivity, and mobility also should be explored.

By the completion of the case history, the clinician should have an impression of the patient's objectives and goals, whether or not they are realistic, the patient's reaction to the vision loss, and discern how much time to spend with the patient. That is, the examiner should sense what can and cannot be covered during the initial evaluation without fatiguing the patient.

Visual Acuity Measurements

Visual acuity measurement, the first test of visual function, follows the case history. The Feinbloom number chart was the first such distance visual acuity chart developed for the evaluation of the "partially blind," as the condition was originally was called (now known as the partially sighted). The chart is filled with optotypes ranging in size from a 700- foot to a 20-foot sized number. Individual pages consist of one to seven numbers. The first chart, however, that Feinbloom found suitable for the low vision patient was the B&L H591 Snellen chart (later known as the B&L AMA rating chart) placed at 10 feet instead of the traditional 20-foot test distance. This became the standard low vision test distance for over 50 years. This chart had optotypes ranging from 200- to 109- foot letters on one side and 97.5 to 20.0-foot letters on the other. The Lighthouse distance visual acuity charts were introduced with optotypes based on Sloan letters. The testing distance was generally 10 feet (recorded in feet) with the patient walking toward the chart or the chart brought toward the patient when the largest line could not be seen. The visual acuity was then recorded as the smallest line seen (e.g., 10/160), hand motion (HM), counts fingers (CF), light projection (LPROJ), light perception (LP), or no light perception (NLP). Counts fingers and hand motion was viewed by many clinicians as an inaccurate method of recording functional visual acuity and is generally no longer accepted by low vision practitioners.

The low vision visual acuity charts in use were not standardized. For example, there was unequal difficulty for each line or page on the eye chart, unequal spacing between letters, chart construction with one to 13 letters on a line, and various style optotypes, including serif and sans serif.

Dr. Jan Lovie and Dr.Ian Bailey, rectified the chart confusion by designing a new type of eye chart. The new chart, which was based on a logarithmic progression became the basis for the Ferris Bailey chart used in the Early Treatment Diabetic Retinopathy Study (ETDRS).

Procedure With the Distance Acuity ETDRS Chart
The rear illuminated Ferris-Bailey ETDRS visual acuity charts are designed to be used at 4, 2, or 1 M. They are available in three randomly arranged letter charts, a number, HOTV, and Landolt C configurations. Visual acuity can be noted in the metric, Snellen, or LogMar systems with this chart. Visual acuity is taken without correction at 4 M in the right eye with the left eye occluded and repeated for the left eye with the right eye occluded. Binocular visual acuity is also taken. The chart should be moved in to 2 M or even I M when the top line cannot be seen. Correction is to be used in cases with significant refractive error such as high myopia or aphakia. The examiner also should instruct the patient in viewing eccentrically during the taking of visual acuity. This procedure introduces the patient to the techniques of eccentric viewing while also demonstrating that the vision may improve if the fixation changes from a central to eccentric area.

Peeking, unintentional though it may be, frequently results in misleading visual acuity measurements. The examiner should therefore closely watch the patient's eyes even when the eye is covered with a paddle occluder or clip-on occluder (e.g., Halberg, Bernell).

Recording of visual acuity is noted as test distance over letter size in meters. Visual acuity, for example, is noted as 4/20-2, 2/32-1, or 1/40. To find the 20-foot Snellen equivalent, multiply the numrator and denominator by 5,10,or 20 for the 4-,2-, and 1-meter test distances. The Designs for Vision number chart is still of value in estimating visual acuity less than 1/40 (20/800). When acuity falls below that which can be recorded on standard eye charts, the examiner should test for light projection, light perception, or no light perception. The upper range for successful visual rehabilitation with low vision optical devices is 1/40. Cogenital or determined low vision patients, however, often succeed with low vision aids when the visual acuity falls below this range.

Incoming Near Visual Acuity Recording

The objectives of the near visual acuity test are to determine the visual acuity as well as the habitual working distance. The later is often indicative of uncorrected refractive error.

Using the Lighthouse "GAME" card and recording the acuity in M notation, the instructional set given to the patient is to read the smallest word at their normal reading distance using the habitual reading correction. Again, visual acuities are taken with the right, left, and both eyes. The Lighthouse "NUMBER" card can be used as well as the Designs for Vision Near Reading Cards for the Partially Sighted. Test distance and card used should be noted on the record.

Careful attention should be paid to illumination. Adjustable lamps for reading should be readily available. Conversely, the examiner should also note whether decreased illumination enhances performance.

External Examination

The external evaluation, which follows visual acuity measurement, should include pupillary position, size, and responses, and position of the lid, eyes, and orbits and nystagmus. It is important to note any change from either the previous status or the information provided on an incoming eye report.

It is also important to take note of any information that might provide clues on the prescription of low vision devices. For example, large sector iridectomies might be the cause of a complaint of photophobia, whereas unequal pupillary positions might influence the type and position of a telescopic lens.

Carefully note the monocular pupillary distance and any height anomalies in the position of the pupil. As previously pointed out, this information will be of value in the positioning of any telescope.

Transillumination is always to be performed in suspected cases of albinism and differential diagnosis. However, transillumination also should be done when the decrease in visual acuity is not always explained by the findings presented from the low vision evaluation.


Keratometry is an objective finding that should be performed on the initial evaluation even when nystagmus is present. It should be performed after corneal and especially cataract surgery since the amount of cylinder, and axis of the cylinder, may shift over time.

Keratometry is also an important technique in establishing the integrity of the cornea. For example distorted mires might indicate the development of keratoconus, irregular astigmia, while a flat cornea might be indicative of micro-ophthalmus.

Keratometry is also an especially useful procedure for estimating astigmatic error in the nonverbal patient or child.

Static and Subjective Findings

Static retinoscopy is preferably performed with a wide aperture trial lens using a trial frame or by over-refracting with a Halberg type clip. In addition to the standard retinoscopy techniques, the examiner should use radical and off-axis retinoscopy. That is, move in when a poor or no reflex is seen, or until some motion is detected. Move the retinoscope off the line of sight to see if a reflex can be obtained. This is especially useful in high myopia or individuals with small pupils.

Subjective evaluation is also generally performed with the retinoscopic finding placed in the trial frame. The bracketing lenses are dependent on the incoming acuity. For example, the bracketing lenses used with an incoming acuity of 4/40 (20/200) is ± 1.00. This is derived by taking denominator of the Snellen fraction and dividing it in half. The bracketing lenses for acuity of 2/40 (20/ 400) would be ± 2.00, while the lenses used for 1/40 (20/800) would be ± 4.00. If the acuity improves during refinement, for example, from 4/40 to 4/20 (20/100), the bracketing lens should also be changed to ± .50 because the sensitivity is increased to smaller lens changes.

Predicting the Add

One of the keystones of the low vision evaluation is predicting the add. This information will be used in the selection of the low vision aid such as spectacle, hand magnifier, stand magnifier, or telescope.

Placing a +2.50D lens over the best distance subjective distance correction, in either a trial frame or Halberg-type clip, hold the Lighthouse Near Visual Acuity Test Chart (Modified ETDRS with Sloan Letters, second ed. at 40 cm. Viewing the chart monocularly, read the smallest line and record the acuity in M notation. Repeat the procedure with the left eye and with both eyes. If the 8 M line can not be read, place a +5.00D lens in the trial frame and read the smallest line with the chart held at 20 cm. Note the dioptric power necessary to read 1 M print under the column, denoting 40-cm or 20-cm test distance.

Sum the predicted add to the subjective refractive correction. For example, a -10.00 myope reading 4 M would require a + 10.00D lens to read 1 M. This could be achieved by removing the distance correction when reading. The same individual reading 8 M would require a +10.00 D correction lens (A +20.00 D add). Conversely, an aphakic patient with a prescription of +14.00 = -2.50 X 90 reading 4 M would require a starting lens of +24.00 = -2.50 X 90. The same individual who could only read 8 M would need a lens of +34.00 = -2.50 X 90, while the emmetrope reading the same 4 M would need a +10.00 add.

The add predicted with the ETDRS chart is single-letter high-contrast visual acuity. Proceed with either the Lighthouse Continuous Text Card for Adults for Near Vision or children) to determine reading acuity. This card, which contains sentences from 8.0 to 4.0 M on one side and 3.2 to 0.4 M on the other is used at a 40 cm with a +2.50 add. The predicted add is generally higher with reading then single-letter acuity.

Additional tests of visual function should follow the prediction of the add. These tests include the contrast sensitivity test, Amsler grid, brightness acuity test, and visual fields.

Contrast Sensitivity Testing

Contrast sensitivity testing with the Vision Contrast Test System is done at 1 M with the best corrected distance subjective and a +1.00 add (for absolute presbyopes). The patient should be instructed to look at the four bottom patches on the chart while the examiner demonstrates that the patches contain either lines going up and to the left, up and to the right, straight up, or the patch is gray. Pointing to each patch, the patient should demonstrate the direction of the lines with his hand. Proceed to the next line when the patient reports that the patch is gray or they are incorrect. Guessing should be encouraged.

The contrast sensitivity is done monocularly and binocularly with the recording done on the sheet provided for the 1- test distance.

The information provided by the contrast sensitivity test often will helpful in determining monocularity verses binocularity, increased need for illumination, necessity for occlusion, the need for control of brightness and contrast, and the need for a higher than predicted add.

Amsler Grid

Hold the Amsler grid at 33 cm. With the best distance correction and a +3.00 add, note the responses monocularly and binocularly. Variations include using the Amsler grid containing diagonal lines for fixation.

The Amsler grid can also be used for a quick determination of a severely constricted visual field. By introducing a 3-mm wand from the periphery, with the patient fixing the central dot, the examiner will be able to determine fields as small as 1 degree.

Visual Fields

Standard tangent screen and modified for the low vision patient, as well as static and kinetic perimetry should be performed where indicated. The Goldmann (Topcon) bowl perimeter is recommended for the evaluation of peripheral fields.

Brightness Acuity Test

The Mentor BAT Brightness Acuity Tester can be used to subjectively determine the effect of a glare source. While viewing through the aperture in the BAT and wearing the best subjective distance correction, the patient reads the distance ETDRS chart under low, medium, and high settings. The fellow eye is occluded.

The BAT can also be used as macular photostress test when the aperture is closed.

Additional Tests

Slit-lamp evaluation, direct and indirect ophthalmoscopy, and tonometry should be performed as needed and where indicated. However, additional testing procedures that are not routinely performed during low vision evaluation may be regarded as necessary, especially, for example, if there is a sudden change in vision. The patient should be referred back to the primary eye care practitioner or other specialists for these prodecures. They may include the following: electroretinogram (ERG); visual evoked potential (VEP); electro-oculograrn (EOG); potential acuity meter (PAM); laser interfornetry; ultrasound (A and B scan); fluorescein angiography, and fundus photos. Computed axial tomography (CT) scans, magnetic resonance imaging (MRI), and analyses of blood chemistries and blood pressure also may be performed.

Marketing and Promoting a Low Vision Practice

Managing a successful low vision practice involves many areas. However, without the addition of new patients and the return of satisfied previous patients the practice will not survive. Marketing and promotion is the process of “showcasing” your practice. It is o.k. to let people know what you do! This can and should be done both internally for existing patients and externally for prospective patients. Following these suggestions will give you practical ways of promoting your practice and insuring its success.

Begin by informing current patients of the low vision care you provide. Don’t be hesitant to let primary care patients know that you may be able to help their elderly parents see more clearly and have a better quality of life. Using practice literature such as brochures, newsletters and statement stuffers is an excellent and cost effective means of notifying patients that you are now providing low vision care.

Meeting and exceeding patient expectations is also very important. Patients are often surprised when you tell them that they can be helped. When the help becomes a reality they are thrilled. This presents a golden opportunity for you to ask them to refer a friend or relative who may need your services. Successful low vision patients are a very vocal group and love to tell their story to others.

Communicate to your low vision patients and their families by sending a narrative report. Patients appreciate receiving the results of their examination and your recommendations for low vision aids. Your thoroughness will be recognized and patients will recommend others to you for low vision care services.

Suggestions for external promotion can include having successful patients contact local medical editors of TV, radio or newspapers to do a story featuring their success with using low vision aids. These human interest stories are very compelling when they show how low vision care helped patients improve the quality of their lives.

You can achieve a similar effect by creating an advertisement that looks like a feature story. Or you can create an advertisement that highlights to low vision patients “SOMETHING CAN BE DONE”.

Association with senior aid companies such as Senior Pathways is also very effective. These companies provide a wide range of services to the senior community and enjoy their trust. When they trust you, they will promote low vision care and your office to the patients they serve.

Contact school districts within your area informing them that you can provide services to help their visually impaired children to do better academically and socially. These services are generally not being provided and school personnel are very great full to have you as a resource.

If there is a large senior center close to your office you can have an informal tea for the residents. Invite them to come and learn more about their ocular conditions and how low vision aids can help.

Informing doctors in your area of the low vision care services you are now providing is always a good idea. Inviting them to refer patients to you for co-management is something they may not expect. By providing a co-management mechanism they are more likely to refer, as they know the patient will return for primary care services. Don’t forget to send letters to the patient’s other doctors as well. They are another good source for referrals.

All of these recommendations work but it takes time to establish your low vision practice and more importantly, its reputation. Don’t give up. Be persistent in your marketing strategies and consistent in giving excellent care. Patients are slow to change but are fiercely loyal when they do. The benefits are well worth the effort.


A patriotic and principled leader visits Sankara Nethralaya

As part of his efforts towards instilling the values of patriotism, team spirit and a service orientation among the employees Dr SS.Badrinath had organized for the visit and guest lecture of a towering leader whose movement had these as its core values, the man was Shri Mohan Madhukar Bhagwat, Sarsanghachalak (Supreme Chief), Rashtrya Swayamsevak Sangh. The proceedings at the packed to capacity Sri VD Swami Auditorium on the 21st of August 2013 started aptly with a patriotic song rendered in Rag Desh considered an intensely patriotic Raga by Dr.Vandana. Thanking the guest speaker for his presense and extending him a warm welcome on behalf of Sankara Nethralaya, Chairman Emeritus Dr SS.Badrinath remarked in jest that it was perhaps the nature of the rather basic questions posed by him to Shri Bhagwat almost 4 years ago that prompted him to make a visit to Sankara Nethralaya and put things in the right perspective. He recalled with gratitude the association of leading lights of the RSS movement like Shri Kasinathan, Shri H.V Seshadri and Shri Sudharshan with the Sankara Nethralaya and their contribution to its growth, highlighting that it was Shri Shivaramji Joglekar a committed member of the RSS who played a critical role in educating the people of the region on the need for eye donation and created awareness on the same and how the seed sowed by him went on to mature as the CU Shah Eye Bank.

Delivering the guest lecture Shri.Mohan Bhagwat observed that his visit and interaction with the members of Sankara Nethralaya was a part of his larger initiative of travelling and meeting the people of Bharath. Members of the Sankara Nethralaya family were highly impressed to note that the Chief of one of the most well knit, organized and disciplined movements was underlining that the need of the hour was ‘Sajjan Shakthi’ or the need to inform, educate and communicate which would translate into better communication and networking among leaders who were doing good work in their own areas, the very same qualities that their Chairman Emeritus had been strongly advocating and emphasizing as the mantra for the institution’s growth and success in his recent meetings and interactions.

Touching upon a variety of topics from women empowerment, total prohibition and answering questions from the audience Shri Mohan Bhagwat underlined the basic point that the word ‘Hindu’ stood for Universal thought and an inclusive culture which embraced and respected many differing views and it was not really a religion as it was commonly understood. Recalling Swami Vivekananda’s clarion call for the coming together of the Science of the West and Indian Spiritualism as the need of the hour the leader appealed that it was the right time for Bharath to stand up and show the way to the world going through turbulent and confused times. He observed that the role of the RSS was not to impose any particular ideology or faith on its cadre but to create bold and just men and women of upright moral values and high caliber who would in turn take the right and well informed decisions and lead their teams in the right way in whichever office or role they occupied. The spirited speech came to an end with his positive note that the number of nationalists far outnumbered the extremists and hence we should face and overcome the threat of terrorism boldly.

A special eye screening camp for special people

“Sometimes I need only to stand wherever I am, to be blessed.” – Mary Oliver

On the 25th August, a team of Senior Optometrists (Ms. Jameel Rizwana H, Dr. Krishna Kumar R, Ms. Vijayalakshmi A), M.Phil Optometry students (Ms. Archayeetha and Mr. Neeraj Kumar) and Optometry fellows (Mr. Danny Lewi Hau, Ms. Jasmine Jose and Ms. Uma Paul) from the Elite School of Optometry and Sankara Nethralaya witnessed the paradise on earth during their visit to the paradise home located at Muttukkadu. The special eye screening camp for the mentally challenged was organized by Mr. S.V.G Subramanian, Deputy Manager, eye bank and Mr. Raman from the “Daasya” an NGO, as an awareness creation and relief providing exercise to mark the ‘National Eye Donation Fortnight’ being observed between August 25th and September 8th 2013. This home serves around 70 people with special needs, primarily those with Mental retardation. Every one of the inmates deserves to be called a child though their physical age varied between 10 and 45 years.

Vision screening that comprised of assessment of visual acuity and functional vision, estimation of refractive errors, assessment of eye alignment and gross eye health assessment was done. Out of the 56 who were screened, refractive error was found in 27 children, anterior segment abnormalities including cataracts in 7, and strabismus in 10 children. Single vision glasses for near vision were distributed to 4 people. Further management including distribution of glasses and referral has been planned.

As eye and vision care professionals, catering to the needs of these special children gave the team a special sense of satisfaction a fulfilment to their profession, the mood of the team could be best captured in the following lines.

“You’ve developed the strength of a draft horse while holding onto the delicacy of a daffodil … you are the mother, advocate and protector of a child with a disability.” -Lori Borgman

Chennaiites gallop for a righteous cause at the ‘Terry Fox Run’

The bright Sunday morning on 25th Aug 2013, saw the ever calm campus of IIT Madras, came alive with a milling crowd of over 15,000 men, women and children of all ages and walks of life, gathered enthusiastically for a major cause – to support the ‘Marathon of Hope’, ‘to spread awareness on CANCER’, with the same spirit as its initiator, “Terrance Stanley ‘Terry’ Fox”, a Canadian athlete and a cancer research activist.

The event named as “Terry Fox Run” is held across the world and was brought to India by Akash Dube who fell victim to cancer after putting up a strong fight. The Rotary Club of Madras East organized the 6km walk at IIT Madras to raise funds for Cancer Research. The event was flagged off by the Chief guests, Dr.S.S.Badrinath, Chairman Emeritus, Sankara Nethralaya, Lt. Gen VK Pillai, Chief of the Southern Army Command and Officer’s Training Academy and Sri.L.S.Ganesh, Dean, IIT Madras.

Speaking on the occasion, Dr.Badrinath said he was extremely glad to see such a large gathering on a Sunday morning expressing their solidarity with the fight against cancer; he expressed his gratitude to the Rotary Club of Madras East, which had organized the massive event for the cause of eye cancer research.

All along the run were fervent participants including infants clinging on to their mother’s arms, the feeble and the old and the ever spirited youth, all geared to send a clear message – to spread cancer awareness. The crowd was emotionally charged when the critical message was delivered by a palliative care patient, who despite his ailment actively took part in the run.

The Sankara Nethralaya stall put up at the venue educated the eager participants on the evils of Retinoblastoma – a cancer of the eye, caused in children and the research activities of the foundation, to aid complete cure, with the help of posters and hand-outs. The grand rally closed with a strong message to the world at large on the need to create awareness on cancer and its prevention. The Terry Fox grant for cancer research would be made available to Sankara Nethralaya to support its research initiatives in retinoblastoma.