National Health Insurance Scheme (NHIS), Universal health coverage and the Nigerian Optometrist Part 1.

The world health organization (WHO) define Health as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.

Health care is known as one of man's fundamental needs. The cost of health care has been on the rise for decades now owing to increasing population, increased life expectancy, rise in cost of hospital equipments amongst other things. Skyrocketing cost of healthcare, the effect it has on families and communities brought about the concept of universal health care.

Eye care, a microcosm of the health care concept, comprises the primary eye care, the secondary eye care and tertiary eye care systems. The eye health care concept is fundamental to a healthy eye and by extension to a healthy body.

 WHO (2012) estimates there are approximately 314 million people around the world whose vision is impaired, due either to eye diseases or uncorrected refractive errors. Of this number, 45 million people are blind and over 110 million in need of low vision aid.

The direct and indirect cost of visual impairments and blindness to the society and especially to the individual runs into hundreds of million dollars. The direct cost is measurable via cost of performing eye surgery, cost of having a comprehensive eye examination, the dearth of eye care professionals and eye care structures etc. Indirect cost is measurable by measuring the activity of daily living quotient. 

Universal health care, sometimes referred to as universal health coverage, universal coverage, or universal care, is a health care system which provides health care and financial protection to all its citizens. universal health care system incorporates the primary health care system that focuses mainly on prevention, early detection and planned management of diseases or illnesses.
The concept of secondary health care, which includes active use of medication to manage diseases, illness and or injuries, the use of surgery to remove, replace or amend tissues or organs. And tertiary health care system, this health care system is focused on rehabilitative care e.g. low vision care etc.

Historically, Germany is credited as the first country to start up a universal health coverage for its citizens as early as 1883! As at 2009, we had about 58 countries with one form of Universal health care or another. {1}
 Nigeria is eager to achieve Universal Healthcare Care. Since its launch in 1999, the National Health Insurance Scheme (NHIS) has been the major initiative to expand health insurance in Nigeria. However, as of mid-2012, NHIS still covered only about 3 percent of the population (5 million individuals). {2}

There are four models of health care systems as put forward by Physicians for a National Health Program (PNHP), Chicago (2010). {3}

 I will discuss them briefly:

a) The Beveridge Model: In this system, health care is provided and financed by the government through tax revenues of the government. This is known as the single payer model of health care system. This means that the government determines what type of health care services is been provided for the individual, what the doctors will charge and the individual is not expected to pay for his health care services! The government acts as both the regulator of funds and regulator of health services provided. This model is named after the author, William Beveridge.
Countries practicing such model include Britain, Cuba, Spain, most of Scandinavia, New Zealand and Hong-Kong.

b) The Bismarck Model: This model of health care system is regulated by government, financed through payroll deductions from employees and employers of labour known as health insurance fund. It is often a no-profit insurance scheme and it is aimed at providing health care coverage for everyone. This is a multi-payer system of health system and named after the Prussian Chancellor Otto Von Bismarck, who invented the welfare state as part of the unification of Germany in the 19th century. Countries that practice this model include Germany, France, Belgium, Japan, Netherlands, the USA( though it practices a variant kind!) and to an extent Latin America.

c) National Health Insurance (NHI) Model: This model adopts the Beveridge and Bismarck systems of health care provision. Government-run insurance scheme are paid into by the citizens and the government on its own provides fund via taxation  to fund the NHI model. Government regulations control how the health fund is used both in private and public health care facilities. Countries that practice this system include Taiwan, Canada and Nigeria.

d) Out-of-Pocket Model: This model requires payment from the pocket when the patient goes to see a doctor. This is common in many rural areas in Africa, Asia etc were health care facilities are either moribund or health care facilities  are not readily in place.

Majority of Nigerians and Africans practices the out-of-pocket model till date, the remaining minority especially those working in state, federal civil services and those working in banks, multinational companies etc are covered under the NHI Model and/or the Bismarck Model of health care!

No doubt that health insurance scheme is cost effective, but enormous challenges abound as to the effective implementation of this scheme in the country partly as a result of inadequate legislation, corruption and outright distrust of the portfolio handlers, the government. These are some hitches that frustrate the effective take-off of the scheme in Nigeria since it was made law in 1990 . The 2014 National Health Bill passed by President Goodluck Jonathan last year can be said to have put to rest a lot of the challenges raised above. We are looking forward to a more participatory health insurance scheme in the country when the policies in the bill are implemented from the second quarter of 2015.

How does eye health care service benefit from NHIS scheme in Nigeria? Of what effect is the National Health Bill of 2014 to the rising cost of eye care services in Nigeria today? How will NHIS bill affect the direct and indirect cost of visual impairment and to blindness in the country? How do the eye care professionals key into National health insurance scheme? Legislatively, can the eye care business be said to have a better representation in the 2014 National Health Bill 2014? I will discuss the questions raised above above in a subsequent blog while analyzing them in the light of WHO's requirements for achieving Universal health care goals, they include:

1) A strong, efficient, well-run health system.
2)  A system for financing health services.
3)  Access to essential medicines and technologies.
4)  A sufficient capacity of well-trained, motivated health workers.

To be continued...

Ebola Virus Disease (EVD) and what Nigerian Optometrist should know...

In that moment you thought that Human Immunodeficiency Virus (HIV) is ravaging  people all over the world in an pandemic scale, Ebola Virus Disease (EVD) suddenly props up dealing mortal blows at its victims, creating an epidemic!

What is EVD?

EVD, formerly called Ebola hemorrhagic fever,  is a severe and often fatal virus infection in humans and primates. It is a form of hemorrhagic fever caused by genus Ebolavirus, a member of  Filoviridae family according to a WHO publication.

Filoviridae is a family of single-stranded RNA viruses that infect vertebrates, that have a pleomorphic usually bacilliform or filamentous shape with a helical nucleocapsid and a lipoprotein envelope with glycoprotein projections, and that include the Ebola viruses and the Margburg virus.{1}

Viral hemorrhagic fever (VHF) is an acute febrile syndrome characterized by systemic involvement, which includes generalized bleeding and severe infections.{2}

 According to a world health organization (WHO) publication, the genus Ebolavirus comprises 5 distinct species:

• Bundibugyo ebolavirus (BDBV)
• Zaire ebolavirus (EBOV)
• Reston ebolavirus (RESTV)
• Sudan ebolavirus (SUDV)
• Taï Forest ebolavirus (TAFV).

 BDBV, EBOV, and SUDV have been associated with large EVD outbreaks in Africa, whereas RESTV and TAFV have not. The RESTV species, found in Philippines and the People’s Republic of China, can infect humans, but no illness or death in humans from this species has been reported to date. {3}

 EBOV has a mortality rate of between (77-100)%;  SUDV has a mortality rate of between (53-65)%; and the Margburg virus has a mortality rate of between (20-50)% .{4}

BDBV has a mortality rate of between (34-47)%. {5}

What we need to know:

Biomedical science first encountered the virus family Filoviridae when Margburg virus appeared in 1967 in Margburg, Germany. {6}
According to a world health organization publication, Ebola first appeared in 1976 in 2 simultaneous outbreaks, in Nzara, Sudan, and in Yambuku, Democratic Republic of Congo. The latter was in a village situated near the Ebola River, from which the disease takes its name.
between 1976, when it was first seen in Africa, till date EVD had affected people within some African regions:{4}
In 1976, Sudan had 285 reported cases with 53% mortality rate.

In 1976, Congo Democratic Republic (formerly Zaire) reported 318 cases with 88% mortality rate.

1977, CDR, reported one case with 100% mortality rate.

In 1979, Sudan had 34 cases with 65% mortality rate.

1994, Gabon recorded 44 cases with 64% mortality rate.
Same year, Ivory Coast had one reported case with 0% mortality rate.

CDR had another major outbreak with a reported case of 315 and 77% mortality rate in 1995!

In 1996, 37 cases were reported in Gabon with 57% mortality rate.

In 1997, 60 cases were reported in Gabon with 75% mortality rate.

In 2000, Uganda had a reported case of 425 with 53% mortality rate!

In 2001, it was Gabon again with 65 cases and 82% mortality rate reported. 

2002, CDR, cases reported were 8 with 83% mortality rate. 2003, CDR, cases reported was 143 with 90% mortality rate. Same year, CDR reported another 42 cases with 69% mortality rate.

EVD is not a death sentence, but a highly contagious disease due to the virulent nature of the causative agent.

Re-emergence
The re-emergence of the Ebola outbreak started in a village in Guinea with a total number of 543 suspects and confirmed cases of EVD, including 396 laboratory confirmed and 394 deaths since it re-emerged this year it then spread to Liberia (834 suspects and confirmed EVD cases, including 200 laboratory confirmations and 466 deaths) and Sierra Leone (WHO reported a cumulative total of 848 suspects and confirmed cases, including 775 laboratory confirmed cases and 365 deaths) according to a Centre for Disease control and prevention (CDC), 2014 Ebola outbreak in West Africa: Ebola Hemorrhagic fever, highlight.

Patrick Sawyer, a U.S citizen,  became the first known victim of Ebola to die in Nigeria. As at the last count, the country has recorded 4 deaths including that of Patrick Sawyer. A Doctor, who attended to late Patrick Sawyer, was released from a quarantine of 10 persons after she  spontaneously recovered. There are 177 direct and indirect contacts to late Mr Sawyer being observated in Lagos and 21 in Enugu state.

Transmission
Ebola is extremely contagious, it transmitted by contact with blood, feces or body fluids from an infected person or by direct contact with the virus, as in a laboratory. People can be exposed to Ebola virus from direct contact with the blood or secretions of an infected person.

This is why the virus has often been spread through the families and friends of infected persons: in the course of feeding, holding, or otherwise caring for them, family members, health workers who "treat" the victims and friends would come into close contact with such secretions. People can also be exposed to Ebola virus through contact with objects, such as needles, that have been contaminated with infected secretions.

The fruit bats of the Pteropodidae family particularly species of the genera Hypsignathus monstrosus, Epomops franqueti and Myonycteris torquata, are considered possible natural hosts for EVD.
Other carriers of this virus are the green monkeys, great Apes, gorillas and even dead or wounded animals. Any contact with those affected animals likely leads to transmission to a human host!

This virus has been isolated from dead bodies, hence people are advised to handle dead bodies suspected to be victims of EVD with care.

Treatment
Currently, there is no proven cure for Ebola.Victims are treated with supportive therapy with the hope that they will recover, though Zmapp and the controversial Nano Silver has been trending recently. Zmapp was administered to two American "Doctors" infected with EVD and another Spanish priest. The later did not survive though.

Nano Silver is promoted by Dr Rimi for its "strong" anti-pathogenic effect at the cellular level but in some quarters, this cocktail's efficacy has been questioned.{7}

Meanwhile, the best way not to be infected with EVD is not contacting it. The research continues though.


Symptoms
The early symptoms of the virus are said to mimic the symptoms of malaria or flu at first. They include high fever, headache, muscle aches, stomach pain, and diarrhea. 

There may also be sore throat, hiccups, and red and itchy eyes ( allergic conjunctivitis, tangelesias, sub-conjunctival hemorrhage, conjunctival hyperemia). A study in Kikwit, CDR, after a 1995 major outbreak infecting 103 people with 84 deaths and only 19 survivors, conjunctivitis was reported in 42% of those that died and 47% of those that survived. Further more, it was noted that 3 of the early onset manifestation that appears to be more suggestive EVD include: bilateral conjunctival injection, maculopapular rash and sore throat with odynophagia (pains on trying to swallow), and always associated with fever [temp: >37.5*C] as the most common symptoms (93% of the time there is fever!).

"Am therefore of the opinion to handle patients with acute red eyes and presented with sudden onset of fever with utmost care! I advice we refer such to a general practitioner to rule out EVD."

The symptoms that tend to follow include vomiting and rash and bleeding problems with bloody nose (epistaxis), spitting up blood from the lungs (hemoptysis) and vomiting it up from the stomach (hematemesis), chest pains and bloody eyes (conjunctival hemorrhages). 

“Hemorrhaging symptoms" begin 4 – 5 days after onset, which includes hemorrhagic conjunctivitis, pharyngitis, bleeding gums, oral/lip ulceration, hematemesis, melena, hematuria, epistaxis, and vaginal bleeding,” reports the Pathogen Safety Data Sheet from the Public Health Agency of Canada. {8}

In its late stages, Your bloodstream starts to fill with small blood clots, which slows the blood. Some of these clots stick to blood vessels' sides. (This is called pavementing, because the clots resemble a mosaic).
These clots are very dangerous; they clog up capillaries, which shuts off blood supply various parts of the body, such as the kidneys, lungs, intestines, liver, brain, and throughout the skin. Your skin starts to get these little red dots all over it, which are hemorrhages under the skin (petechiae). It attacks connective tissues that hold your organs together, destroys collagen, and liquefies the under layers of the skin. White blisters appear alongside the red dots (called a maculopapular rash, and looks like tapioca pudding). Rips easily occur in the skin, and hemorrhagic blood spills out. The rash develops into bruises, and the skin becomes pulpy and soft. Your connective face tissues are destroyed, and your face takes on hollow, mask-like look. 

Your eyes also turn bright red, and may be fixed in one position (optometrists take note). Your gums, mouth linings, and salivary glands start hemorrhaging. The surface of the tongue turns bright red, and dissolves. The lining of your throat also dissolves. Then the black vomit starts... Your heart starts bleeding in itself, and blood starts to fill the chest cavity. Blood clots in the brain kill brain cells, which is known as sludging of the brain. The linings of the eyeballs may fill with blood, and you could go blind. You may even weep blood. 

You could possibly have a hemispherical stroke, in which parts of your body may become paralyzed, or could be fatal.

Since your organs are clogged with coagulated blood, the blood that you bleed does not clog, the red blood cells having been destroyed, those organs/tissues die while you are still alive... The liver turns yellow, bulges, and may start to dissolve. The kidneys may fail, the spleen hardens, and the intestines fill with blood. If the victim is pregnant, she will abort her baby, which is filled with Ebola virus particles and has red eyes.

EVD destroys the brain thoroughly, and you would probably have epileptic convulsions, or grand Mal-seizures. The entire body violently shakes. If you don't die from a stroke or organ failure, then you will have to suffer from "crash and bleed".... like you might see depicted in some horror zombie flick! You hemorrhage through almost every opening of your body. Your body, already damaged from shock, heated by fever, and slowly being destroyed tissue by tissue, quickly "crashes" from blood loss.  After the body is clinically dead, body tissues (skin, organs, etc.) liquefy, and the fluids are filled with Ebola virus particles.{4}

In general, it takes about 2-21 days (average incubation period) for symptoms to become visible.

According to reports, people who have the virus aren’t contagious until symptoms become visible.

What do we need to do?

Every patient that reports for eye check should be requested to have his or her body temperature checked among other parameters like the blood pressure, weight, pulse etc. Anyone with fever and sudden conjunctival hyperemia should be watched and preferably accessed by a general practitioner.

In absence of a general practitioner, the person's full blood count (FBC) is requested cos it often gives clue to EVD. The first line of defense in our body, the macrophages, neutrophils, monocytes etc are highly suppressed in hemorrhagic fever.

EVD is not airborne, though it has been isolated borne on aerosol suspended in the air!{9} . 

It is highly advised that we should wear a nose/mouth mask while performing direct ophthalmoscopic examination, hand-held Goldman applanation tonometry or even Schiotz type of tonometer! The air puff tonometry should be the more appropriate in this type of scenario.

EVD is a contact disease. The virus can be transmitted when it comes in direct or indirect contact with a new host. It is therefore advised to ensure we wear re-useable gloves that can be disinfected immediately after attending to a patient. Always wash your hands with disinfectant soap after attending to a patient. Our trial lens frame or the phoropter head should be disinfected with methylated spirit after seeing every patient. When contact equipments are used in the clinic, the least you can do is to disinfect it with methylated spirit.

Do not send home someone you suspect of any of the above symptoms. Let the fever component be of particular interest, others like conjunctivitis and the acute onset of this fever be very suggestive for further action.

The Public Health Agency of Canada explains that virus can survive in liquid or dried material for a number of days. Infectivity is found to be stable at room temperature or at 4 C for several days, and indefinitely stable at -70 C. There is need therefore to disinfect our door knobs, in the clinic and at home. 

A message to Optometrists:
What could be faulted as the pathophysiology of conjunctival hyperemia often associated with proven cases of  EVD? Does conjunctival involvement predict survival or death in those with EVD? Can ocular involvement and fever be consistent enough for EVD diagnosis? 

There is certainly much work to be done, researches to be carried out, bearing in mind that most survivors of EVD end up with chronic ocular complication. As the window of the body to the world, can't some unknown be revealed of this deadly virus since our country is not fully equipped to identify this deadly virus.

It is important as primary eye care professional to develop visual"clues" that may be very helpful... This writeup is retrospective because there has not been any active research work to this end. The onus of proof lies with us.
 

EVD is a national emergency situation, we should stay prepared and be ready to help in containing this virus and learning more about it.

Ebola is real, a real manace to humanity. We should confront it with ferocity it deserves...

Dr Victor Ezebuiroh.


{1} (http://www.merriam-webster.com/medical/filoviridae)

{2} (Peter B. Jarhling, PhD*; Aileen M. Marty, MD†; and THOMAS W. Geisbert, PhD: Viral Hemorrhagic fevers. Medical aspects of biological warfare Chapter 13; p272)

{3} (http://www.who.int/mediacentre/factsheets/fs103/en/)

{4} http://www.tpida.org/files/Filoviridae.pdf)

{5} http://en.m.wikipedia.org/wiki/Bundibugyo_virus]. 

{6} Martin GA, Siegert R, eds. Marburg virus disease. Berlin: Springer Verlag, 1971.)

{7} http://drrimatruthreports.com/dtra-confirma-ebola-nano-study/)

{8} (http://www.phac-aspc.gc.ca/lab-bio/res/psds-)

{9} Peters and LeDuc. Ebola: The virus and the disease. The Journal of Infectious diseases 1999; 179(Suppl1): xi.]

A holistic metric based analysis of Optometric practice especially in private practice!

"Although optometrists are taught the quantitative science of optics and spend most of their workday taking measurements of visual acuity, most do not invest much time to measure the state of their business. More often they form intuitive impressions about business issues. Then they make decisions without a solid, metrics-based understanding of their actual situation and without any quantitative norms against which to compare their performance."
[Key Metrics: Assessing Optometric Practice performance, 2011 Edition (Introduction).]

The Management & Business Academy™ (MBA) is a metrics-based approach to optometric practice management. Since 2005, MBA has gathered comprehensive information on the characteristics and financial performance of over 1,800 private optometric practices in the U.S. There is this popular narrative, "Whatever you measure improves." This is the primary call to action that presupposes introduction of measurement in growing Optometric practice.
With the heavy reliance of eye care health sector on private practicing optometrist in Nigeria, I decided to point out those metrics with the intention of providing insights as to how to grow our practices, because it is said: "Where the money goes, so goes the authority."- and the power too!

Tagged Total Practice Productivity Metrics, it discusses the overall productivity of a practice and empirically analyze them:

1)Gross Revenue per Exam:  This is defined as the gross revenue per every comprehensive eye examination at any given time. This metric is singled out as, "...perhaps the single most useful measure of practice productivity..."
It is influenced by the internal processes of your practice and can be improved by the actions of the practitioner.
If H represents the gross revenue receipts in a given time frame, X(0,1,2,3,4...) representing comprehensive eye examinations carried out on a patient in the same given time frame... (0,1,2,3,4...) represents what constitutes a "comprehensive" eye examination and the internal processes of practice! The later identified in numerals has the tendency of influencing gross revenue earned and highlighted in note below

Hence, H/X (0,1,2,3,4...)................................................................. (i)
= Gross Revenue per Exam!

Note:
a) Number of eye tests carried out.
b) Types of high end user frames on display.
c) Products on display such a medications, contact lenses, surgical practices, low vision care etc
d) Turn-over of patients
e) New patient flow
f) Size of practice etc
Influences the "Gross Revenue per Exam" metric.


2) Exams per OD hour: This is defined as, "The number of complete eye exams performed during each hour an optometrist works." It is an empirical reproduction of revenue generated per OD hour. The key variables impacting this metric are size of the patient base, recall effectiveness, extent of delegation of testing tasks to staff, exam process efficiency and appointment scheduling efficiency.

If X(0,1,2,3,4,...) represents the comprehensive eye examination on an individual patient, Hx represents the optometrist's work rate in an hour, therefore,

Exams per OD Hour would be stated empirically thus:

X(0,1,2,3,4...)/Hx.................................................................... (ii)

Apart from adding a new OD, the main way solo OD practices can grow is to increase patient traffic per hour! The primary determinant of this metrics is efficiency of the OD in the clinic measured per hour!

3) Gross Revenue per Staff Hour (non-OD Staff): This metric is a ratio of the total revenue gained in a specific period of time divided by the total number of non-lab/non-OD staff hours worked during the same period.
This metric is a measure of how efficiently patients are managed administratively in a given OD clinic. It also determines how under-staffed an OD clinic is and triggers hiring of more non-OD staff or firing as the case maybe!

Lets take H as the gross revenue receipts in a given period of time.
Let Ns represent the non-lab/non-OD staff hours worked in a given period of time.

The Gross Revenue per Staff Hour can hence be mathematically represented thus:

H/Ns................................................................... (iii)

Note: Gross Revenue per Staff Hour is dependent on the following factors:
a) Number of staff members
b) Exams performed per hour
c) Gross revenue generated per exam
d) Patient traffic.

4) Gross Revenue per OD Hour: This is a ratio of the gross revenue in a given OD hour. It is a measure of how productive an OD uses his time in generating revenue in a given time measured per hour. It also correlates with the productivity of the staff members on how they efficiently attend to patients administratively! This metric correlates strongly with the clinical efficiency of the OD measured in hour! It is strongly suggestive of how successful the clinical practice is.
Other parameters that correlate with this metric include:

i) Revenue per OD hour
ii) Practice size
iii) Practice growth
iv) Improved OD time utilization.

If the Gross Revenue generated, often indicated by the gross revenue receipt generated in a given period of time, is H,

Let the OD hour be indicated by Ohr;

Therefore, Gross Revenue per OD hour can be mathematically represented thus:

H/Ohr...................................................................... (iv)

5) Complete Exams per 100 Active Patients: This is a metric that indicates the recall rate success of patients. A patient is said to be active if he had completed at least one circle of complete eye examination in a particular OD clinic within a given period. One circle of complete eye examination includes at least on recall examination. That being said, it should be noted that this metric is not dependent of the size of the clinic. The following factors can influence the recall rate, viz.
a) Recurrent ocular conditions like Vernal conjunctivitis especially in Children, Dry eye syndrome in adults etc
b) Chronic conditions like ocular manifestations of Diabetes, Hypertension etc...
c) Glass prescriptions for pediatric patients and for binocular anomalies etc.

It is noted that the average recall rate of active patients is about 28 months especially in OD clinics with more than 70% revenue generated from glasses especially for presbyopes! Hence, an OD clinic with 50 exams per 100 Active Patient is said to have an above average successful recall rate!

6) Annual Gross Revenue per Active Patient: This is the ratio of the Gross Revenue generated in an annum in relation to every active patient seen within the same period. It measures the recall rate and revenue per exam.

7) Gross Revenue per Square Foot of the Office Space: It represents how efficient clinic space is fully utilized and translated into revenue recouped either traffic of patients and multiple examinations carried out simultaneously in a clinic space to improve the OD hour, thereby increasing the gross revenue earning. It is weakly correlated to increase in practice size. It is a particular relevant consideration when ODs plan to expand their practice size... Like introducing Slit Lamp Bi-microscope, Automated central visual field analyzers, lens fitting lab etc. Again, when an OD clinic is moving to a new location, this metric helps in determining space size of new location.

The metrics described above have helped developed OD clinical practice in the USA especially for private practicing Optometrists. Subsequently, this blog will discuss each metric in details such that local contents will be developed. Because my primary interest is to synergize these growth concepts with what is obtainable in our country such that efficiency in practice could be achieved.

Finally, I want to say a big thank you to the developers of Management & Business Academy™ (MBA), Practice Advancement Associates (PAA), a unit of Jobson Medical information. To reach PAA, contact Al Greco at agreco@jobson.com.
Hope you enjoyed this piece.
Long Live Optometry in Nigeria!
Long Live Nigeria!
Dr Ezebuiroh Victor Okwudiri.
(This is strictly a free blog with no financial obligation anywhere!)

World Sight Day... The dawn of a new era!

Today is world sight day. This year's celebration marks a new road map to actualizing vision 2020. The theme for this year is "Universal Eye Health". The action plan in line with WHO's initiative for vision 2020: the right to sight with a "Call To Action"- Get your eye tested!

What is World Sight Day?
 

World Sight Day (WSD) is an international day of awareness, held annually on the second Thursday of October to focus attention on the global issue of avoidable blindness and visual impairment. It is co-ordinated by the International Agency for the Prevention of Blindness (IAPB) and became an official IAPB event in the year 2000, and has been marked in many different ways in countries around the world each year since then. 
 

World Sight Day is the focal Advocacy and PR event for IAPB and its members and partners each year, highlighting the fact that 80% of blindness is avoidable (i.e. preventable and/or treatable) – 4 out of 5 people have avoidable visual impairment. 

WSD provides a platform for organisations to encourage governments, corporations, institutions and individuals to actively support global blindness prevention efforts.

WSD is co-ordinated by IAPB under the VISION 2020 Global Initiative. The theme, and certain core materials are generated by IAPB. All events are organised independently by members and supporter organisations.

Do you know that on this day IAPB members (of which Nigeria is among) work together to:

• Raise public awareness of blindness & vision impairment as major international public health issues
• Influence Governments/Ministers of Health to participate in and designate funds for national blindness prevention programmes
• Educate target audiences about blindness prevention,  about VISION 2020 and to generate support for VISION 2020 programme activities?

Looking back:
 

In 2007 October 11, the "Call For Action" was "Vision For Children" which targeted causes of blindness and visual handicap in children.

In 2008 October 9, the "Call For Action" was "Eye on the Future: fighting visual impairment in later life" which targeted causes of blindness in the elderly, their causes and approaches to manage them, but above all measures to avoid them was brought to limelight.

In 2009 October 8, the "Call For Action" was "Gender eye health: equal access to eye care" aimed at bridging the gap in access eye care among the sexes. It tend to ensure that women were given equal opportunity at eye care as men!

In 2010 October 14, the "Call For Action" was "Countdown to 2020". A reflection of how far we have gone in our quest to eliminate avoidable blindness and what needs to be done were brought to the fore-front and ironed out!

In 2011 October 13, the "Call For Action" was "Working together to eliminate avoidable blindness" were Optometrists, Ophthalmologists and other health care professionals were called up to work together such that avoidable causes of blindness can be eliminated. It put into cognizance the strained relationship between us and other eye care professionals and health care professionals towards the issue of  blindness or visual  impairment.

In 2012 October 11, there was no "Call For Action", it was aimed at allowing eye care professionals to develop priority areas aimed at putting words into actions such that the birth of the next Road map towards achieving the primary goals of World Sight day celebration can be crafted.

This brings us to 2013!
 

2013 is a special year in that a new road map for 2014-2019 is put forward with an overall theme of "Universal Eye health." The intention is to find a way to universally include primary eye care into universal primary health care service. Visual impairment is on the increase and primary eye care is the easiest way to bring it down to a very low level.

The key message of this new road map are as follows:

• Approximately 285 million people worldwide live with low vision and blindness
• Of these, 39 million people are blind and 246 million have moderate or severe visual impairment
• 90% of blind people live in low-income countries
• Yet 80% of visual impairment is avoidable - i.e. readily treatable and/or preventable
• Restorations of sight, and blindness prevention strategies are among the most cost-effective interventions in heath care.
• The number of people blind from infectious causes has greatly reduced in the past 20 years
• An estimated 19 million children are visually impaired
• About 65 % of all people who are visually impaired are aged 50 and older, while this age group comprises only 20% of the world's population
• Increasing elderly populations in many countries mean that more people will be at risk of age-related visual impairment.

We have not gotten there, we should not relent because we will certainly get there.
for more information go to www.iapb.org.
Thank you World Health Organization and International Agency For Blindness Prevention for not relenting in ensuring the actualization of Vision 2020.

An after thought:

I am currently organizing school children for eye examination to find out those in need of glasses. New Eyes for the Needy International donated about 1080 free frames for distribution to those in need of glasses. I will give out 300 glasses to children in schools within Bonny Island and provide reading glasses for school teachers. It is a week-long event!
 Do you know that World Teachers Day fell on this same day?
You can call it co-incidence, but I call it a reward to our teachers who made us who we are today! Happy Teachers Day! Happy World Sight Day!


GET YOUR EYES TESTED TODAY!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!

Optometric practice in Nigeria and quackery in eye care profession!

"We must not let anyone else write our future.” 

(Dr. Ronald Hopping, President, American Optometric Association, June 2012.)

The practice of Optometry in Nigeria is without doubt improving into a medical care service especially in private health care setting and in eye hospitals despite the host of challenges that confronts us.

For instance the average MBBs physician keeps flinching at any association of Optometrist as "Doctors"! It is not only those MBBs members that gets all goose-pimpled at associating the Optometrist with "doctor"! Some ignorant nurses and allied health workers find it very difficult refer us as such.

 

But who is a "Doctor"?

1) A licensed medical practitioner who administers treatment for the benefit of ameliorating symptoms, managing signs by applying "professional" judgement.

2) A PhD holder in any academic field.

Does it matter whether we are called a Doctor? Or does it benefit more to develop in proficiency? Do we claim what we are not? That is by the way.

In a bid to checkmate the influx of Optometrists into the health care mainstream, efforts have been on top gear to discredit our role via propaganda and systematic cutting off of funding (the "call duty" phenomenon) by the government and our "Head of Departments". But do we really need the government before we stick to our ethics? Do we really need mainstream government to have a reviewable, current & water-tight code of conduct that mirrors professional practices internationally?

In other to play dirty, some Optometrists in Nigeria are gripping hard on each others jugular veins in a vice-like manner. Like two elephant in a brawl, the helpless grass (the at-risk populace) have been left to bear the blunt providing quacks the opportunity to operate with ease!

It is no longer news that most ophthalmic nurses are today parading themselves as "eye doctors" to fleece victims of money and dishing out blindness. Also on record are so many of these "orthodox" eye doctors, diploma Ophthalmologists etc who junket the country doing the opposite of vision 2020!
Quackery is when we do not adhere to what we profess!

a) A matured cataract patient was recently "couched" by such doctors and this man's eye today is worse off with pigmentary glaucoma and NLP (No Light Perception).

b) A bifocal reading glass given to a child of 16 years with myopia and against the rule astigmatism.

c) A topical steroid prescribed by a nurse for a "red eye" secondary to angle closure glaucoma.

d) Practicing without a license.

f) Poor adherence to ethics of practice.
g) Lack of compliance to Optometric code of conduct
h) Poor acquisition of professional continuing education & competency
i) Snail-speed update of our current school curricular, scope of practices etc...

They are but few of the travesty orchestrated by quacks in the practice.

I have not seen any health care profession than the eye care sector that has been so infested by quackery courtesy of the "silent" imbroglio between Optometrists and Opticians on one hand and the entire NMA (Nigerian Medical Association) & Ophthalmologists on the other hand.
In a bid to get at the primary eye care practitioners, NMA, Ophthalmologists have variously cooked up spurious and fabricated propaganda aimed at slandering us or belittling us. They go to such low levels as to blocking our growth in area of competency! Why is residency in Optometry as seen in MBBs here in Nigeria not been approved? They are everywhere, at the National Assembly, in health Ministries, in politics as politicians painting us as parasites (as recently portrayed by a medical doctor in my place of practice!)...  Did the recent strike embarked by Nigerian health workers ring a bell? The manner in which they were frustrated? The ease in which those super human "NMA" board disgraced their efforts to make it look like they are not supposed to have a say! Until their bubble is burst, we will be seeing these actions repeat itself over and again in the coming days and in the future.
In the Nigerian health care system they call the shots because they are always elected head of health ministry, from the minister of health to even health departments in local hospitals! They command the money, as we all know where the money goes so too does authority! They are on course to asphyxiate Optometry at all cost, hence the few Ophthalmologists in their folds are doing their dirty jobs for them.
They spew out half-baked Ophthalmic nurses, ship them off to practically all state and federal hospitals in every location in Nigeria to replace Optometrists as primary eye care providers! It may sound incredible, but it happens right in front of us! When we (Optometrists) started agitating especially through our serving corps members, they gave us few slots and ensured that many of us are disgraced out of the milk cow! They came with the rebellious call duty allowance, then with other flimsiness that includes our lack of surgery skills etc As if that was not enough, they have encouraged all sorts of impunity in eye care profession such that today, eye care examinations are equated as freebies by politicians to win elections!
And you know what? We follow those crumbs were ever it takes us to the detriment of our profession. Indirectly, shop owners have seen the "illegality" as an avenue to sale their over the counter reading glasses & the "patient" or "victim" sees little difference in patronizing the "quack", who often gives out their product for much lower prices than the professionals! By the way, they will say: "Is it not that same glass they gave me when so & so politician or philanthropist organized "free eye test" for us & even without even testing my eyes I was given a reading glasses?" "Therefore I can easily get a reading glass like that one in a shop!"" They conclude.
"Quacks" have gone ahead to indulge in harmful ocular surgery practices because of the overwhelming number of persons blind as a result of cataract and other conditions like Glaucoma, retinopathies etc
Why won't it be like that, on record in Borno state Specialist Eye centre are some Ophthalmic nurses who perform cataract extraction without license to do so, just because Ophthalmologists are using them to get at us! Ophthalmologists prefer "training" them to help them (the Ophthalmologists) in the theaters while undermining our position in pre- & post-cataract co-management of such patients! Little wonder most victims do not know they are going to slaughter like lambs and like sheep they do not complain until their eyes get compromised!
On the part of Optometrists, we do not strictly adhere to our codes of conduct! We practice often times without understanding our oath of practice. Ethics? Even fewer commit to them. We need to become stricter and more serious in combating such criminality, as well as build ourselves into the colossus our founding fathers dreamed for us!

An after thought...

Earlier today in our, "Optometrists Lounge" Facebook page an update drew my attention to some major issues hitting us directly in our faces:
1) Discrimination in payment parity with members of the NMA (Nigerian Medical Authority) in Hospitals- Government and Private.
2) Headship disparity especially as in departmental heads in hospital, private or public with the consequence of favoring their group more than others.
3) Finally, the contentious CAP 463 Act establishing the "University Teaching Hospital Act" which overtly skews in favor of the medical doctors, for instance in the provision for the members that make up the "Board" in Cap 463 LFN Section 2, Sub (1) a-j; unduly favored the members of NMA than other post-graduate trainable professionals like Optometrists as in (a), (d), (g)!
 Could it be the reason why residency in optometry in Nigeria is still an uphill 4-year task in isolated universities without the backing of Government?
Just a morally laden rhetoric question though...
4) The term "Consultant" as an exclusive right of the NMA members as put forth in their recommendations to the FG in health care reform number (1.20).
5) In number (1.23) of their (NMA) recommendations in the FG's Health reform act, they pointed out the lack of need for post-graduate programs akin to Residency in medicine to Optometrist!

Definitely a pattern is being perfected here and we cannot afford to just fold hand and let the implosion gets complete.
We need to curtail such impunity because it is doing the health care arena no good.
Optometrists are primary health care providers and as such should not be lumped together as mere dispensable or collateral damage in the health care community. They need that degree of "freedom" to practice whether in the private or public sector such that they can perform efficiently.

 We have a choice to make...

1) That as a body-ODORBN- ,we, should get our acts right by infusing confidence in our students through re-visitation of our academic curricular to embrace the realities of 21st century Primary eye care providers.

2) We should buy over the at-risk populace over with our people-oriented eye care services such that "quacks" will not find a safe haven to operate.

3) We need to research, form very strong advocacy groups, encourage international Optometric bodies to partner locally with us and invest deeply in eye care if we want this rape of our collective efforts in the eye care sector not become a spite to our individual abilities.

4) We should revisit our code of conducts, add vigor to our ethics and bridge the gap with other health care practitioners such that the second fiddle rating we are subjected to is recanted. We can do better.

A stitch in time save nine!

Nigerian Optometry introduces a residency program!

I got the information below from this website: http://www.medicalworldnigeria.com
This is to inform all qualified Doctors of Optometry, wishing to undergo a 4-year post-graduate training, leading to the award of Fellowship of the College in any of the specialties, that the primary examinations for admission into any of the faculties has been scheduled as follows:
DATE: October 12th 2013
VENUE: Department of Optometry, University of Benin, Benin City.
TIME:  11:00am.
QUALIFICATION: Any intending applicant should possess the following
qualifications:
a) A degree of O.D (Doctor of Optometry) from an institution accredited by the Optometrists and Dispensing Opticians Registration Board of Nigeria (ODORBN)
b) A3year Post NYSC clinical experience
c) Must be in good standing with ODORBN
EXAMINATIONS WILL BE TAKEN FOR THE FOLLOWING FACULTIES/SPECIALTIES
a. Primary Care Optometry  b. Public Health Optometry  c. Cornea and Contact Lens Practice
d. Rehabilitative Optometry and Low Vision Care  e. Paediatric Optometry  f. Ocular Health
e. Orthoptics
METHOD OF APPLICATION: Pay an Exam fee of N30,000 (Thirty Thousand Naira) only into:
Account Name: -Nigerian College of optometrists
Account No.  1000957051
Keystone Bank (formerly bank PHB) Asaba Branch.
COLLECT APPLICATION FORM ON PRESENTATION OF YOUR BANK TELLER AT ANY OF THE UNDER-LISTED ADDRESSES:
1. Dr. Mrs. O.U.Amaechi
Department of Optometry
Abia State University Uturu
2. Prof. F.O Iwuagwu
Department of Optometry
Imo State university Owerri
3. Dr. Emma Esenwa
Department of Optometry
Federal University ofTechnology Owerri
4. Dr. E.lyamu
Department of Optometry
University of Benin
5. Dr. (Mrs.) N. Aruotu
Department of Ophthalmology
University of Port-Harcourt Teaching Hospital
6. The Registrar
Optometrist and Dispensing opticians
Registration Board of Nigeria
No.8, Harvey Road, Yaba, Lagos.
7. Dr. Damian Echendu
Optometry unit
State House Medical Centre Aso Rock,Abuja.
CLOSING DATE:All completed forms must be returned to the point of collection not later than 5th october, 2013
Prof. Uche Ikonne
Registrar.

Residency in Optometry in Nigeria is a welcome development. But we need to understand the following:



1) NOA website has been suspended, I do not know for how long now. I went to look up the information circulating around on residency in Optometry in Nigeria, but came up with nothing! Why should we not know what is going on? ODORBN website does not have such information too! Then why hastily publishing it to the outside world without communicating in-house first of all? We are in Information Age and ignorance has no place here.
2) If this is residency, why does it take 4 years here while it takes a max of 2 years in the USA to attain fellowship and one year for residency?
3) What is the salary allowance for the residents, just as it is done in MBBs and in American Optometry residency program?
4) How will this program be funded? By who? How will it be sustained?
5) Examinations should be conducted by an independent body made up of technocrats without any partisan sentimentality and whose primary priority is hinged on objectivity!
6) Why is the information so wrapped-up in secrecy to so many of us and only leaked in National newspapers and in the conferences?
We need inclusiveness in this bold step the profession has decided to take into the future. But for christ's sake, we need to understand what is happening. I so believe in Nigerian Optometry that am willing to join hands with all and sundry to make this program work... For it to work though, need more than mere wishful thinking and grandiosity. Long live Nigerian Optometry!

The continuing euphoria of Nigerian Optometry in Residency!

In my last blog, "Nigeria Optometry and the Euphoria of Residency", I ruffled hats, stepped on big toes and even went as far as opening cans of festering worms on which the foundation of this noble profession has been standing on since its inception in this country!

But what is residency in Optometry? Where is it currently practiced? What need is residency to an Optometrist?

Optometry has functionally developed into a medical eye care, with some Optometrists designated as Optometric physicians. In some states in the USA, Optometrists are allowed to perform surgeries! (See my blog: "Optometry and were the future of eye care lies..."). 

Historically, Optometry introduced its first residency program in 1975 and Dr Thomas Stelmack became the first post-graduate resident of Optometry in 1976 at the Kansas city VA hospital. (History of Optometry in the VA. Robert D. Newcomb, OD, MPH).

It all started in the USA, the Veteran Administration hospitals. Before 1972, optometry schools had virtually no interface with medical hospitals and clinics and teaching clinics were in the schools or clinics serving the poor, blind or homeless. Founded in 1930, the Department of Veterans Affairs was swamped with returning WWII veterans in 1946 and first given congressional mandates to affiliate with medical, dental and nursing schools and tie into their student and residency training programs. This was a boon to the medical schools, giving them access to large inpatient populations and funds to support faculty and residency training programs while the VA gained skilled, board certified physician specialists and medical students and residents who rendered considerable patient care as part of their training.  In effect, in 1946 the Congress directed the VA to reorganize its hospitals as “teaching hospitals”. Soon almost every medical school was affiliated with a VA hospital and most medical students and residents rotated through them.  VA physicians were required to be board certified in a specialty. 

Congress,in 1973, enacted legislation (PL 93-82) requiring the VA to establish an optometry program.  An expanded mandate was given in 1976 (PL 94-581) which was the equivalent of the 1946 mandate for medical and dental care by calling for the VA to increase its number of ODs and establish teaching affiliations with optometry schools. A pilot student Optometry training program begun in 1973.  The development and growth of VA Optometry training programs were the result of policy arising with the congressional committees with VA oversight that determined an optometry service within VA hospitals with students and affiliated schools were the best means to meet unmet needs for eye care. This integration continued to accelerate while VA worked to define areas of residency training within its hospitals in cooperation with the Association of Schools and Colleges of Optometry and to create an accrediting process for the new optometry residency programs in cooperation with the American Council on Optometric Education.
(Culled from "ABCMO - Overview of ABCMO and History of Board Certification.")

The current pattern of Optometry residency in the USA, requires:
a) American Council on Optometric Education (ACOE) to accredit the candidate's Residency
program.

b) National Board of  Examiners in Optometry (NBEO) to administer the candidate's specialty examination.

c) American Board of  Certification in Medical Optometry (ABCMO) to give recognition to granted specialized "board certification".

Note: 

ACOE is the only accrediting body for professional optometric degree (O.D.) programs, optometric residency programs and optometric technician programs in the United States and Canada. ACOE, formerly referred to as Council on Optometric Education, was first established in the 1930 Boston AOA. In 1934 it was ratified. In May 2001, it became recognized by Council for Higher Education Accreditation (CHEA).

NBEO is a body required by the American Optometric Association (AOA) to administer board certification examinations for licensure, license renewal and for specialty examination to enter into residency program. It was formed in 1951 by Association of Regulatory Boards of Optometry (ARBO) and Association of schools and colleges of Optometry (ASCO).

ABCMO is a body created to provide practitioners, medical facilities, government and state agencies and  the general  public a uniform national standard to identify optometrists with advanced competence in the medical diagnosis, treatment and management of primary and secondary disease and dysfunctions of the human eye, adnexa and visual tracts. It was established in 2009.

Residency in Optometry is a one year program designed for Optometrists who have graduated with an OD. A residency allows the doctor to gain specialized skills and information in a specific area of Optometry.
Residency in Optometry is a teaching hospital based program aimed at providing the OD physician with advanced skills and knowledge in medical eye care. We are living in times of advanced medical care, technologically, ethically and ideologically. It behoves of the profession to take the bull by the horn with the aim of advancing eye care to embrace the realities of 21st century.

Do not forget this:

Residencies have many benefits. To start with, a residency is known to increase the knowledge, skills, clinical experience and self-confidence in the O.D. physician. On top of that, the O.D. practitioner should be able to build relationships with professors, mentors, other residents and students, Optometric legislators, industries, clinicians, as well as other healthcare professionals.

(Residency Programs Grow: Amber Hirley, ASCO NL, UAB)

Truth is that the Optometrist is trained to become a general eye care practitioner, but specialization in eye care community has shown to hugely benefit us especially in area of competence and actualization of vision 2020: The right to sight.
Nigerian Optometrists are called on today to put it out to our law makers within the profession and in our state and National houses of Assembly to develop a residency program which has been shown to help in research and advanced competency in the profession, but above all, it has shown to have a tremendous effect in main stream eye medical care sector!

Nigeria Optometry and the euphoria of residency...

After 6 years of studying Optometry in Nigeria, one sets out into the job market tagging a Doctor of Optometry (OD) along. Then comes the unending quest to find a good place to do the compulsory 1 year internship, just like our Medicine and Surgery counterpart! By chance, you may be fortunate to do it in a federal establishment but in most cases the scenario depicts a sorry state of of our internship program (I will discuss that in a subsequent blog). The young Optometrist intern is left in the cold, either used as a marketer by senior Optometrists or used as a money bag by other more sinister senior colleagues of ours. Imagine a situation were a young Optometrist intern, devoid of the necessary clinical experience been thrown into the hordes of darkness, in the market square to scout for customers and make glass sales without recourse to our ethics!
Then he/she finishes the internship and zooms off for the compulsory 1 year NYSC (National Youth Service Corp) to serve their father's land! Just like our Medicine and Surgery colleagues, we all go to serve our father's land. We suffer, we sweat, we put our lives on the line to serve the nation patriotically. Yours sincerely even have to face the threat of Boko Haram while providing eye care services in rural Bama, Jere, Munguno etc all in the name of vision 2020! What came out that? We had to escape via the whiskers when Boko Haram's threat became viscous. Then NYSC finishes.
The job market keeps toying with us, we have to live on the benevolence of the health ministry to get us job in federal establishment. As if that is not enough, some colleagues go practically begging for food or live by the harsh reality of underemployment!
Then our Medicine and surgery colleagues, enjoying a better pay and the plum jobs out there and truly living out the Doctor title. They prepare to go into various specialties in our various institutions to do their residencies... But the Optometrist colleague? We are left to wait for 10 years post NYSC before we can embark on post graduate studies in university of Benin! Is it a residency program? I doubt it. But all the same we do not have a residency scheme for NYSC Optometrists neither do we have an internship scheme befitting this beautiful profession in Nigeria.
Oh what a lost cause! No wonder the medical doctor, a colleague of mine in a hospital were we co-practice, preparing to go into residency in internal medicine asked me if we do not take post-Med school exams. I was thrown aback but that is life for you! Oh Optometry were goeth thou?
Hope you got the message. Pass it on...
Dr Ezebuiroh Victor Okwudiri
N/B: This article has no financial interest!

Bi-Temporal Hemianopia- a clinical finding!

Hello, welcome to yet another exiting blog... Read on!

It was a normal clinic day, on a week day to be precise; I was expecting patients that morning, as was the usual norm in a medium scale Optometric practice. This man walked in that I should help him work on his glasses( I also fit and mount lenses for my patients; not forgetting other optical works like frames adjustments, repairs etc to increase eye care services and hence reduce all forms of health care duplicity as encouraged by the health care terrain of our country!) I put up discussion with him and in no long time he opened up to me about his eye condition that has been on for 3 years now.
The man, 46 years, has a progressive bilateral distant blur that increases with peripheral gaze. He has associated near blur, feels disoriented sometimes which he attributed to the persistent "eye problem"! His Optometrist in Lagos gave him glasses for sight and for reading, gutt: Voltaren i tds x1/12 and eye antioxidants that he has been using for 3 years on! The problem is that the eyes does not seem to be improving and this patient is preparing to go to "Ijebu" to go and find out from a spiritist who was responsible for his eye condition.
The present glass was already 3 years worn habitually by the patient so I asked him to run some tests to enable me renew his glass prescription.
His visual acuity @ 6 meters:
RE: 6/9
LE:6/9-3
&
Visual acuity @40 cm
BE: N8
He used his habitual prescription to read the visual acuity chart (+0.75 DS add 2.25)
Refraction
RE: +1.00 DS 6/9
LE: +1.25 DS 6/12 (It turned out that the retinoscope light probably dazzled his eyes!; after 10 minutes, he read 6/9-2 with the same power ipsilaterally.)
At near +2.50 DS was added on his distant retinoscope finding to give him N6 OU! ( Do you understand anything unusual here?)
No meaningful improvement with the new retinoscope finding, objectively and subjectively! Again, this man's age and the near add shows an underlying condition that seems to be suppressing his near acuity! Or else why will a 46-year old man use a combined +3.50 DS readers and still cannot use it to see N5! Hmmm...
Funduscopy was carried out and the bilateral temporal- peripheral retina of each eye showed haziness and choroidal vascular degenerations, more prominent on the left eye than on the right eye!
His cup-to-disc ratio is OD 0.3, OS 0.3 an associated pallor not consistent with glaucoma nor optic nerve atrophy was seen. The diagnosis was blurring around its edges, the symptoms greying out such that subtle and sublime dynamic skills was required to arrive at a tentative diagnosis with sketchy information available. So what could be the cause? Was I getting confused? Should I leave him with his habitual management regimen or do I explore other options?
Plan: IOP (intra ocular pressure) measurement with Handheld Goldmann Applanation Tonometer, central visual field examination and dilated funduscopy of both eyes!
His intra ocular pressure on OD=14.5 mmHg, OS=14 mmHg @ 4pm! Central visual field result showed a bi-temporal scotoma, prominent on his OS than OD with macular sparing of both eyes, dilated funduscopy of both eyes showed choroidal vascular degenerations probably extending to the Ora serrata area (Do not judge me cos there was no indirect Ophthalmoscope to view the Ora serrata proper!)
Still not very convinced, I did some digging into the symptoms of bi-temporal hemianopia and came up with a subtle, but clinically relevant symptom- mental confusion is associated with many cases of Bi-temporal hemianopia! I called his primary eye care specialist in Lagos to inform him of the development and asked the man to run an MRI scan to find out the underlying cause of his condition or to rule out compression of the chiasma by an obstructing tumor and to take the results to his primary eye care physician!
Two weeks later, he returned to thank me generously and even made me feel like a chief priest of Ogun!
He has since been flown to India for removal of the tumor and I feel so satisfied to have been of help!
Note: "Bitemporal Hemianopia is a type of partial blindness where vision is missing in the outer half of both the right and left visual fields. Usually associated with the lesions of the optic chiasms, bitemporal hemianopia causes patients to experience difficulty seeing in both eyes." (www.hemianopiasociety.com/what-is-bitemporal-hemianopia)
Bitemporal hemianopia can be caused by the following:
a) Pituitary adenomas,
b) Craniopharyngiomas, or
c) neoplastic menangiomas
d) aneurysm of the anterior communicating artery which arise superior to the chiasm.
(en.wikipedia.org/wiki/Bitemporal_hemianopsia)
Again, Bitemporal hemianopia causes a damage to the crossing fibers of the optic chiasm which interrupts fibers from the nasal hemi retina of both eyes. The nasal hemi retina relays information that originated from the outer visual field. (http://www.csus.edu/indiv/m/mckeoughd/learningmodules/CtrVisualPathModule.pps)
Hope we started on a positive note? More to come on On same topic soonest! Thank God it is weekend!
Dr Victor Ezebuiroh
We are not doing this for financial rewards, hence no financial attachment! Feel free to share and comment!

Hypertension and the Eye... Pathogenesis?

In my last article on "Hypertension and the Eye... What the primary Eye care Optometrist Should know.", I pointed out some ocular consequences of this systemic condition viz: Retinopathies, changes in refractive status as the eye of the chronic hypertension patient, choroidal degenerative changes and general changes in ocular vascular supplies with an increasing affinity for low vision in subjects.
The ocular effect of hypertension, especially on the collagen matrix making up the most vulnerable portions of the eyes, is not really new to eye care. The ocular blood vessels, the choroidal and retinal surfaces, the crystalline lens, even the jelly vitreous humor are all kept in shape by the collagen matrix that gives structural rigidity to this delicate organ-the eye- and ironically becomes the main connecting tissue to be weakened by hypertension or so I think.
Can the pathogenesis of ocular manifestation of hypertension be explainable by the weakening of the collagen matrix of the eyes? What is the relationship between hypertension disease degenerative condition and collagen matrix weakening effect? Are we saying that maintaining the integrity of the ocular collagen connective tissue matrix is one of the means to manage ocular manifestation of hypertension? What does it mean to have a weakened collagen matrix?
Lets take a detour.
Elastin and collagen are the most important components of blood vessels extra-cellular matrix, giving the necessary strength and elasticity to blood vessels, including the capillaries. The blood vessels- veins, venules, capillaries, arterioles and arteries-characteristically presents with the tunica adventitia, tunica media and tunica intima with their modifications based on function and location.
The capillaries contain no tunica media (the structure the reinforces vascular tensile strength) but has modified endothelium (tunica intima) and oftentimes its tunica adventitia is modified into a base membrane.

In hypertension, arteriolosclerosis and arteriosclerosis collagen, back bone of the vascular connective tissue, is always the victim and the much hyped degenerations associated with this condition (Hypertension) becomes the consequence. Insult on the surrounding vascular endothelium leads to increasing production of collagen in the process of fibrogenesis. Suddenly there is increased proliferation of fibrocytes and subsequent formation of fibroblasts resulting in increase in connective tissue activity, perhaps to ameliorate the insult of the arterial blood pressure/resistance on the vessel! The proliferated formation of new collagen connective tissues in this instance does not follow the normal pattern and hence a less structurally similar network of collagen bundle results to a vulnerable and weakened structure.

Connective tissue (CT) is a kind of biological tissue that supports, connects, or separates different types of tissues and organs of the body. (Wikipedia). Collagen and its extra cellular matrix provides such function in the blood vessels and in short could be seen as a bag or container of less "rigid" body tissues. In supporting the tissues and organs of the body, the connective tissue is known to provide some kind of defense to its content. Eg Fibrosis (a kind of supporting function of the connective tissue) is caused by a series of events, triggered by chronic injury. These events include:
1) immediate damage to the epithelial/endothelial barrier;
2) release of TGF-b1, the major fibrogenic cytokine;
3) recruitment of inflammatory cells;
4) induction of reactive oxygen species (ROS);
5) activation of collagen producing cells;
6) matrix activation of myofibroblasts; and,
7) in the absence of continuous injury, reversal of fibrosis.
(TATIANA KISSELEVA AND DAVID A. BRENNER. Mechanism of Fibrogenesis.Experimental Biology and Medicine 2008, 233:109-122.).

The fibrosis process as outlined above is similar in almost all the structures having collagenous connective tissues but different organs' connective tissues effect different structural adjustments leading to compromised intra-tissue coherence and hence the disintegration/degenerations in the susceptible vessels, tissues, organs etc!

In rats, AKIRA OOSHIMA et al in "Increased Collagen Synthesis in Blood Vessels of Hypertensive Rats and Its Reversal by Antihypertensive Agents. Vol.71,No.8,pp.3019-3023,August1974.", observed increased collagen synthesis and thickening in the aorta, mensentric arteries and to a lesser extent in the heart. They observed that the increased synthesis of collagen is a direct result of the effect of hypertension on these structures.
In end vessels and in very tiny blood capillaries, arteriolosclerosis is induced and its many consequence like vascular rupture in advanced retinopathies, choroidopathies, maculopathies, aneurysms and even breakdown in collagen type ll of the vitreous humor, the collapse of the lamina cribosa, and many more such sclerosis in the vulnerable eye, kidney,heart, distal part of the arms, limbs or cerebral contents!

Little wonder we are faced with multiple ocular signs of ocular manifestations of hypertension, not only that the eyes are reinforced by the collagen network- the cornea has type l collagen, collagen present in the vitreous are types II,XI,VI and IX; the sclera is composed of type l and type lll collagen, the retina is composed of types I, ll, lll, lV, V, VI and XVIII, the retinal vessel is composed of collagen types I, III, IV, V, VI, and XVIII, the choroid is composed of type l, lV and type XVlll, lens capsule collagen consisted mainly of type IV collagen etc- it is almost exclusively held in place by this connective tissue. Varying degrees of injuries are inflicted to these connective tissues in chronic hypertension.

As primary eye care practitioners we are therefore expected to be in the fore-front of promoting preventive health care maneuvers that will reduce the incidence of this, often irreversible, structural changes- anatomically and physiologically- in the ocular plexus. We must ensure that our patients susceptible to chronic and/or acute insult cum injury are kept from harms way by ensuring any of the underlying causes are addressed as early as possible and we should work closely with GPs to ensure that the patients adhere strictly to their medications and check ups! Ones their underlying systemic cause is removed normalcy returns in collagen synthesis and other tissue functions ameliorated. Even if the underlying cause is not the entire system, it is advised that the condition be isolated, if it is within our scope of practice, or referred to a specialist in a co-managed process.
Finally, chronic effect of hypertension can be sight threatening and early detection and management is the best option, we are therefore required to always remind our hypertensive patients of this with the aim of healthy vision of the subjects.
Long live Naija Optometry.
We can do better.
Thanks.
Dr Ezebuiroh Okwudiri Victor.
This article is exclusively my opinion.

ABC of Ocular Pharmacology for Optometrists in Nigeria 2-Drugs terminologies commonly encountered in our practices and their what they mean!

A primary eye care Optometrist, in the rural or urban setting, is faced with the tasks of prescribing ocular medications from time to time. The professional should also be able to read through the drug history of patients as passed on by a former colleague or another medical professional without much hassles.
In our continuing bid to empower the primary eye care Optometrist in Nigeria, Africa and beyond; this blog has decided to put down most of the latinized terminologies on how to write drug prescriptions. It cannot be over emphasized, the importance of such primary knowledge to Optometric practice in Nigeria and beyond.
Excerpt:

Abbreviation	Latin	Meaning
aa	ana	of each
ad	ad	up to
a.c.	ante cibum	before meals
a.d.	aurio dextra	right ear
ad lib.	ad libitum	use as much as one desires; freely
admov.	admove	apply
agit	agita	stir/shake
alt. h.	alternis horis	every other hour
a.m.	ante meridiem	morning, before noon
amp		ampule
amt		amount
aq	aqua	water
a.l., a.s.	aurio laeva, aurio sinister	left ear
A.T.C.		around the clock
a.u.	auris utrae	both ears
bis	bis	twice
b.i.d.	bis in die	twice daily
B.M.		bowel movement
bol.	bolus	as a large single dose (usually intravenously)
B.S.		blood sugar
B.S.A		body surface areas
cap., caps.	capsula	capsule
c	cum	with (usually written with a bar on top of the "c")
c	cibos	food
cc	cum cibos	with food, (but also cubic centimetre)
cf		with food
comp.		compound
cr., crm		cream
D5W		dextrose 5% solution (sometimes written as D5W)
D5NS		dextrose 5% in normal saline (0.9%)
D.A.W.		dispense as written
dc, D/C, disc		discontinue
dieb. alt.	diebus alternis	every other day
dil.		dilute
disp.		dispense
div.		divide
d.t.d.	dentur tales doses	give of such doses
D.W.		distilled water
elix.		elixir
e.m.p.	ex modo prescripto	as directed
emuls.	emulsum	emulsion
et	et	and
ex aq	ex aqua	in water
fl., fld.		fluid
ft.	fiat	make; let it be made
g		gram
gr		grain
gtt(s)	gutta(e)	drop(s)
H		hypodermic
h, hr	hora	hour
h.s.	hora somni	at bedtime
ID		intradermal
IM		intramuscular (with respect to injections)
inj.	injectio	injection
IP		intraperitoneal
IV		intravenous
IVP		intravenous push
IVPB		intravenous piggyback
L.A.S.		label as such
LCD		coal tar solution
lin	linimentum	liniment
liq	liquor	solution
lot.		lotion
M.	misce	mix
m, min	minimum	a minimum
mcg		microgram
mEq		milliequivalent
mg		milligram
mist.	mistura	mix
mitte	mitte	send
mL		millilitre
nebul	nebula	a spray
N.M.T.		not more than
noct.	nocte	at night
non rep.	non repetatur	no repeats
NS		normal saline (0.9%)
1/2NS		half normal saline (0.45%)
N.T.E.		not to exceed
o_2		both eyes, sometimes written as o2
o.d.	oculus dexter	right eye
o.s.	oculus sinister	left eye
o.u.	oculus uterque	both eyes
oz		ounce
per	per	by or through
p.c.	post cibum	after meals
p.m.	post meridiem	evening or afternoon
prn	pro re nata	as needed
p.o.	per os	by mouth or orally
p.r.		by rectum
pulv.	pulvis	powder
q	quaque	every
q.a.d.	quoque alternis die	every other day
q.a.m.	quaque die ante meridiem	every day before noon
q.h.	quaque hora	every hour
q.1h	quaque 1 hora	every 1 hour; (can replace "1" with other numbers)
q.d.	quaque die	every day
q.i.d.	quater in die	four times a day
q.o.d.		every other day
qqh	quater quaque hora	every four hours
q.s.	quantum sufficiat	a sufficient quantity
R		rectal
rep., rept.	repetatur	repeats
RL, R/L		Ringer's lactate
s	sine	without (usually written with a bar on top of the "s")
s.a.	secundum artum	use your judgement
SC, subc, subq, subcut		subcutaneous
sig		write on label
SL		sublingually, under the tongue
sol	solutio	solution
s.o.s., si op. sit	si opus sit	if there is a need
ss	semis	one half
stat	statim	immediately
supp	suppositorium	suppository
susp		suspension
syr	syrupus	syrup
tab	tabella	tablet
tal., t	talus	such
tbsp		tablespoon
troche	trochiscus	lozenge
tsp		teaspoon
t.i.d.	ter in die	three times a day
t.d.s.	ter die sumendum	three times a day
t.i.w.		three times a week
top.		topical
T.P.N.		total parenteral nutrition
tr, tinc., tinct.		tincture
u.d., ut. dict.	ut dictum	as directed
ung.	unguentum	ointment
U.S.P.		United States Pharmacopoeia
vag		vaginally
w		with
w/o		without
X		times
Y.O.		years old

(source: Wikipedia)

The above prescription codes should help during co-management of disease conditions with other health care providers, objectifying our respect in the medical world and developing Optometry in Nigeria into a truly medical eye care profession in line with the dreams of our founding fathers...
I am all for the 21st century trend of Optometry, but I believe we have to earn it; we have to expand, grow and redefine our place in the medical world!
Long live Nigerian Optometrists,
Long live Optometry!
Compliments of the season!