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a tax receipt. Not only are you helping children and their families, you receive a
personal benefit as well.
CHANGE
OF
ADDRESS
Your contribution will ensure the PGCFA can continue to –
• provide you with important information on treatments, new and innovative research
and stories you can relate to through our website and newsletter
• host our annual Education Day
• encourage new discoveries through our research awards
Please note that the PGCFA has
recently changed its mailing
address. The new address
effective immediately is:
Here are three ways you can make a difference:
1. Direct your annual United Way pledges to the PGCFA by listing the
PGCFA’s charitable number on the back of your pledge form.
Our charitable number is: 89268 4960 RR0001.
2. Make a one-time or recurring donation on-line at www.pgcfa.org
– it’s fast, easy and secure. All major credit cards are accepted.
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
3. Mail your contribution to:
PGCFA
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
You can also email us at
info@pgcfa.org or phone us at
416-444-4536.
Your Support Will Make a Difference
The Pediatric Glaucoma and Cataract Family Association is a volunteer group, committed to promoting
the quality of life for children with glaucoma and cataracts and their families by:
• Providing information and education • Providing support
Together, we can help children see the sun, the moon and the stars.
For more information, visit our website at www.pgcfa.org
To support the Pediatric Glaucoma and Cataract Family Association, please send in your donation to our
address as listed below. Please be sure to include your mailing address so that we may send you a
charitable tax receipt. Or, to make an online donation, please visit our website at www.pgcfa.org
Canadian Charitable Registration # 89268 4960 RR0001
This is a Canadian publication.
Comments by Canadian physicians
are intended only for residents in
Canada in accordance with the
principles mentioned above.
MORINformation
Volume XVII • Issue 1
• INSIGHT INTO CHILDREN’S GLAUCOMA
In This Issue:
Pg. No.
Contact Lens Options for Infants
and Small Children After
Cataract Surgery
1
Tonometry – Measuring the
Eye’s Pressure in Children
2
A Day in the Life of an
Ophthalmology Resident
4
Book Review – The Blind Doctor
5
Accessibility to Research on Glaucoma 6
We sincerely thank you for your kind support in the past and we look forward to
your continued support in helping children see the sun, the moon and the stars.
Medical information and advice
provided by the PGCFA or physicians acting at their request, does
not represent a prescription and
should not replace the information
and advice given by your own
physicians and other medical
professionals.
Winter 2010
Scientific Advisory Board
Alex V. Levin, M.D., MHSc,
Harvard Medical School
Massachusetts Eye and
Ear Infirmary
FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology Ken K Nischal, FRCOphth
and Ocular Genetics
Head of the Clinical and
Wills Eye Hospital
Academic Dept. of
Philadelphia, PA
Ophthalmology
Fellowship Director
Sharon F. Freedman, M.D.
Great Ormond St Hospital
Professor of Ophthalmology
for Children
and Pediatrics
Hon. Senior Lecturer
Chief, Division of Pediatric
Institute of Child Health
Ophthalmology
London, England
Duke University Eye Center,
Durham, NC, USA
Norm Medow, M.D.
Director of Pediatric
Dr. David S. Walton, M.D.
Associate Clinical Professor of Ophthalmology and Strabismus
at Manhattan Eye, Ear and
Ophthalmology
Throat Hospital, New York City
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Board of Directors
Mike Atwell - Past Chair
Ron Hendrix
Ian Hubling - Webmaster
Alex Levin, MD, FRCSC –
Medical Advisor
Robert Lewis - Fundraising
Monika Mistry
Ray Mistry
Leslie Mowat - Past Chair
Andrea Osborn - Newsletter
Editor
David Prowten - Chair
Russell Schildkraut
Mike Taitz
David Van – Treasurer
Janice Vogtle
PGCFA contact details:
Website: www.pgcfa.org
Email: info@pgcfa.org
Telephone: (416) 444-4536
Postal address:
Pediatric Glaucoma and
Cataract Family Association
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
Bequests and Charitable Giving
6
Eye on the Medical Literature:
Early Exposure to Anesthesia and
Learning Disabilities
7
Navigating the Education System
8
What is a Secondary Cataract?
9
Tax Savings Ideas for the
Visually Impaired
9
News from New York City
10
Announcement: New Member on
Scientific Advisory Board
11
Reading Corner: Luna and
the Big Blur
11
Thank You for Your Support!
Announcement: Change of Address
12
PGCFA Needs Your Help
12
AND
CATARACTS •
Contact Lens Options for Infants and
Small Children After Cataract Surgery
Scott A Edmonds, O.D.
Susan E. Edmonds, O.D.
Wills Eye Institute
Philadelphia PA
ataract surgery involves removal of
the natural lens of the eye. Visual
rehabilitation requires replacement
of this focusing power. Contact Lenses are
manageable for most children with strong
glasses prescriptions and provide the
excellent vision required for normal
growth and development of the visual
system. The correct development of the
brain and the neurological aspects of
vision such as acuity, contrast sensitivity,
binocularity, and depth perception all
require clear, well focused light.
C
One option is a contact lens that provides
full time vision correction, can be tolerated by the cornea for extended wear and
is easy to insert and remove when
required. After cataract surgery, the Silsoft
lens by Bausch and Lomb is a top choice
for these qualities. This lens provides
excellent oxygen for corneal health, is
easy to insert and remove and is available
“off the shelf ” for quick replacement
[Editor’s note: availability may vary in
certain parts of the world]. This lens
option however has some drawbacks: it is
the most expensive lens in the group and in
some children, it is easily ejected from the
eye and possibly lost. It also has an artificial surface coating to make it wettable
and this surface is damaged by handling
and exposure to air. Once the surface is
damaged, it attracts protein and mucous
and the lens becomes unwearable. While
some children with good tear film, blink,
and lid anatomy can tolerate the lens for
months and months, other children will
damage the surface in a matter of days thus
requiring frequent replacement.
The second option is a custom rigid gas
permeable lens. This option has been
around for a long time and has always
provided the best optics, and newer
plastics and computerized lathe techniques
are bringing it closer to the first option.
The lenses now provide plenty of oxygen,
and can be worn on a long time extended
wear basis. Each lens is custom made and
can be adjusted “in office” for an optimal
fit that minimizes ejection, moves freely
and centers correctly. The lens is a bit
harder to insert and remove in a baby or an
uncooperative child but this usually
improves over time. Since the lens has to
This publication is dedicated to the
memory of Dr. Donald Morin,
an international acclaimed expert on
pediatric glaucoma and cataracts.
Helping children see
the sun,
the moon,
and the stars.
Thanks…. to all the contributors to this edition of MORINformation.
12
www.pgcfa.org
...continued on pg 2
1
...continued from pg 1
be custom made, replacements can be an
issue but the turn around time is only a
couple of days and by maintaining a spare
lens, this problem can be well managed.
The cost of these lenses is more reasonable than the cost of the Silsoft. The lenses
can also be cleaned and polished to
maintain a clear optical surface and
extend the life of these lenses for years.
The third option is a custom soft lens.
These lenses are currently only available
in a low water content plastic and therefore cannot be worn during sleep. This
therefore requires daily handing of the
lens. The soft material does not provide
the best optics and is more difficult to
insert. Soft lenses absorb human protein
and environmental contaminates and
therefore must be replaced more
frequently. Since these lenses are a custom
design, the fit and power can provide a
good fit and vision.
The latest option for older post-cataract
children is a disposable soft contact lens
(()2 Optix or Proclear Compatibles) that
requires monthly replacement. The lens is
a larger diameter than the other options
and is difficult to insert in infants and
children under 6. The Proclear lens is a
daily wear lens that cannot be worn during
sleep while the 02 Optix does have a
limited extended wear option. The cost is
very reasonable and similar to typical
disposable lenses.
The contact lenses field is a constantly
changing area. The big advantage to this
form of optical correction is flexibility.
Surgical options such as intraocular lens
implants (IOLs) or refractive surgery
provide a “one time” correction and
cannot be adjusted for growth, development or life long changes in refractive
status. With a little patience and effort,
contact lenses can provide excellent
optical correction at any given point in
time and allow for a lifetime of excellent
vision.
TONOMETRY – MEASURING THE
EYE’S PRESSURE IN CHILDREN
By Sharon F. Freedman, MD
Professor of Ophthalmology and Pediatrics
Duke Eye Center, Durham NC
here are many different types of childhood glaucoma, but
most share in common an elevation of the pressure within
the eye (Intraocular Pressure, IOP). Measurement of the
IOP, called tonometry, can be performed in a variety of ways, but
all involve touching the surface of the eye (on the cornea which is
the front window portion over the pupil and iris) with a device
which then transmits the pressure information to the person doing
the measurement. This is a brief, painless procedure, but it can
pose challenges in young children. Since the IOP can be falsely
raised when a child is upset (straining, crying, or even just
squeezing the eyelids tightly together), it is very important to take
the IOP reading with as calm a child as possible. Small infants
and children can often be cajoled into cooperating with the IOP
measurement by simple techniques such as giving a bottle or
other edible treat, or by distracting the child with a toy or movie
in the office. Tonometry can even be performed in many infants
while they sleep (if we are lucky enough to have them fall asleep
in the office!). All the techniques we will discuss are harder to
use in children with nystagmus (eyes that move back and forth),
and in eyes where the cornea is scarred, opaque, or very tiny.
T
Goldmann applanation, except that the
examiner holds the device in his/her hand
and the blue light is built right into it.
While many ophthalmologists are very
skillful with this technique, it does require
quite a lot of practice, and can be difficult
especially in children who are fearful or in
whom it is difficult to hold the eyelids
open without squeezing. The tip is sterilized between uses.
The Tonopen® is another useful hand held
tonometer that works by applanation
(flattening a small portion of the central
cornea), but differs from Goldmann and
Perkins tonometers in two respects – it
does not require the examiner to look
down the tip of the instrument (hence the
examiner is not “in the child’s face” for
the measurement), and it requires
anesthetic but not yellow dye or any light
source. The Tonopen is very useful for
children with smaller eyelids openings,
and can be easily transported to the
operating suite for measurements under
sedation or anesthetic. Several small
painless “taps” are made with the tip on
the cornea. The tonometer tip is covered
with a new, clean, disposable cover for
each use. The IOP reading is displayed
digitally on the side of the instrument,
along with an indicator of how reliable it
is felt to be (e.g., if five individual
readings are taken and are all very similar,
the reliability of that measurement will be
high). This instrument has been shown to
be reasonably similar to Goldmann appla-
nation, but shares the same difficulty with
corneas which are scarring and children
who strain or squeeze. It can be used in
those with nystagmus.
A very new portable tonometer, the iCare
tonometer (iCare, Finland) has recently
become commercially available. This
device works by a principle of measurement called “rebound”, and uses a very
small plastic-tipped probe which must be
disposed (or at least carefully cleaned)
between uses. Unlike the other tonometers, this instrument does not require the
use of anesthetic to obtain IOP measurements, since it touches the cornea (about
six times) so briefly that the average
person does not even feel it touch. This
means that the child does not have to get
eye drops for the test, thus avoiding one of
the greatest fears of children. The current
model must be used with the child in the
upright position, but the next model to be
released will not have this limitation. IOP
measurements with the iCare tonometer
are reported to be very similar to those
obtained using Tonopen in normal school
children, and most children who try it find
it more comfortable than Tonopen. The
iCare tonometry may actually some day
be suitable for home tonometry by
families of children with glaucoma, and is
currently being developed to allow selftonometry by adults with glaucoma, so
that they will have the ability to monitor
their own IOP at home.
Two additional non-portable tonometry
techniques are worth mentioning briefly.
The first, pneumatonometry, uses air
flowing across a special instrument tip, to
measure the IOP. This device is very difficult to use in the office, but can be very
useful to the ophthalmologist when the
child is under sedation or anesthesia in the
operating room, because it is able to determine the pressure even when the corneal
surface is not entirely clear or smooth. It
is not a machine that is necessary if other
means of pressure reading, as discussed
above, are available. The second technique
is often called “air-puff ” or non-contact
tonometry, because it uses a jet of air to
measure the IOP. Since air-puff tonometry does not require anesthetic or a sterile
tip (because only the air touches the front
of the eye), this technique is commonly
used as a screening test for IOP in many
eye care offices. While older air-puff
machines were not considered very
accurate, more modern devices are
reported to be similar to Goldmann
tonometry in measuring IOP.
IOP measurement in children is still
challenging, but newer technology
promises to make the task less onerous
and more pleasant for children with
glaucoma and for their ophthalmologists.
We still have much to learn about features
of a child’s cornea that affect the accuracy
of these IOP measurements, so stand by
for additional updates in future issues.
COME VISIT US AT WWW.PGCFA.ORG
The available devices for measuring IOP have increased in
number over recent years. Originally the IOP was measured by
placing a plunger-like device on the cornea, loaded with weights
of varying size, until the cornea was indented a certain amount,
and then a table was used to determine the actual IOP (depending
upon what weight was used and how far down the plunger went
as it indented the cornea). This technique, called Schiotz tonometry, is no longer recommended to measure IOP in children, due
to its inaccuracy and the difficulty performing the test on a child.
and eyepieces for the examiner). This technique is performed
after the eye receives a drop containing anesthetic as well as a
yellow dye called fluorescein. Then a blue light is used to view
the end of the tonometer tip (which contains two small prisms in
it), and the tip is pushed forward until it contacts the center of the
cornea. The patient does not feel the tonometer tip touching the
eye. The IOP is read on a dial on the slit lamp, directly in mm Hg
(read “millimeters of mercury”), the unit in which we most often
report IOP). Goldmann tonometry is an excellent technique in
older children, and cooperative children can often perform this
test by the age of about 4 years old. There is also evidence that
very abnormal central corneal thickness can affect the IOP
measured with Goldmann applanation (probably true also for all
other tonometers currently used), although the actual measured
IOP should never be adjusted but rather recorded as it was
measured. The physician can then decide if other factors might
play a role in determining the actual IOP for that given eye.
The “gold standard test” (the one considered the most dependable, and the one used most often in adults), Goldmann tonometry, is performed by placing a device against the cornea while the
child sits at the slit lamp biomicroscope (the device that the child
can put his/her head into and which is attached to a beam of light
Portable devices to measure IOP in children are often much easier
to use than Goldmann applanation, especially in those children
who are small and very active, those with nystagmus, and when a
child is under anesthesia or sedation. The Perkins tonometer is a
hand-held instrument which works in a manner very similar to
2
FACTS ABOUT
GLAUCOMA AND
CATARACTS
FIND
SUPPORT
• Join the email support group and
share information, resources and
support with other parents of children
with glaucoma and cataracts
ASK THE DOCTOR
• Ask our medical professional a question
regarding pediatric glaucoma or cataracts
QUESTIONS AND
ANSWERS
• Search our database of frequently
asked questions regarding glaucoma,
cataracts, medicine or surgery
3
NEWSLETTERS
• View or download current and past issues
• Sign up to receive a free subscription
CALENDAR OF EVENTS
WHAT’S NEW
• Significant medical articles,
most recent issue of the newsletter,
speakers notes from Annual Education Day,
video of cataract surgery
LINKS TO RELATED
WEBSITES
...continued from pg 1
be custom made, replacements can be an
issue but the turn around time is only a
couple of days and by maintaining a spare
lens, this problem can be well managed.
The cost of these lenses is more reasonable than the cost of the Silsoft. The lenses
can also be cleaned and polished to
maintain a clear optical surface and
extend the life of these lenses for years.
The third option is a custom soft lens.
These lenses are currently only available
in a low water content plastic and therefore cannot be worn during sleep. This
therefore requires daily handing of the
lens. The soft material does not provide
the best optics and is more difficult to
insert. Soft lenses absorb human protein
and environmental contaminates and
therefore must be replaced more
frequently. Since these lenses are a custom
design, the fit and power can provide a
good fit and vision.
The latest option for older post-cataract
children is a disposable soft contact lens
(()2 Optix or Proclear Compatibles) that
requires monthly replacement. The lens is
a larger diameter than the other options
and is difficult to insert in infants and
children under 6. The Proclear lens is a
daily wear lens that cannot be worn during
sleep while the 02 Optix does have a
limited extended wear option. The cost is
very reasonable and similar to typical
disposable lenses.
The contact lenses field is a constantly
changing area. The big advantage to this
form of optical correction is flexibility.
Surgical options such as intraocular lens
implants (IOLs) or refractive surgery
provide a “one time” correction and
cannot be adjusted for growth, development or life long changes in refractive
status. With a little patience and effort,
contact lenses can provide excellent
optical correction at any given point in
time and allow for a lifetime of excellent
vision.
TONOMETRY – MEASURING THE
EYE’S PRESSURE IN CHILDREN
By Sharon F. Freedman, MD
Professor of Ophthalmology and Pediatrics
Duke Eye Center, Durham NC
here are many different types of childhood glaucoma, but
most share in common an elevation of the pressure within
the eye (Intraocular Pressure, IOP). Measurement of the
IOP, called tonometry, can be performed in a variety of ways, but
all involve touching the surface of the eye (on the cornea which is
the front window portion over the pupil and iris) with a device
which then transmits the pressure information to the person doing
the measurement. This is a brief, painless procedure, but it can
pose challenges in young children. Since the IOP can be falsely
raised when a child is upset (straining, crying, or even just
squeezing the eyelids tightly together), it is very important to take
the IOP reading with as calm a child as possible. Small infants
and children can often be cajoled into cooperating with the IOP
measurement by simple techniques such as giving a bottle or
other edible treat, or by distracting the child with a toy or movie
in the office. Tonometry can even be performed in many infants
while they sleep (if we are lucky enough to have them fall asleep
in the office!). All the techniques we will discuss are harder to
use in children with nystagmus (eyes that move back and forth),
and in eyes where the cornea is scarred, opaque, or very tiny.
T
Goldmann applanation, except that the
examiner holds the device in his/her hand
and the blue light is built right into it.
While many ophthalmologists are very
skillful with this technique, it does require
quite a lot of practice, and can be difficult
especially in children who are fearful or in
whom it is difficult to hold the eyelids
open without squeezing. The tip is sterilized between uses.
The Tonopen® is another useful hand held
tonometer that works by applanation
(flattening a small portion of the central
cornea), but differs from Goldmann and
Perkins tonometers in two respects – it
does not require the examiner to look
down the tip of the instrument (hence the
examiner is not “in the child’s face” for
the measurement), and it requires
anesthetic but not yellow dye or any light
source. The Tonopen is very useful for
children with smaller eyelids openings,
and can be easily transported to the
operating suite for measurements under
sedation or anesthetic. Several small
painless “taps” are made with the tip on
the cornea. The tonometer tip is covered
with a new, clean, disposable cover for
each use. The IOP reading is displayed
digitally on the side of the instrument,
along with an indicator of how reliable it
is felt to be (e.g., if five individual
readings are taken and are all very similar,
the reliability of that measurement will be
high). This instrument has been shown to
be reasonably similar to Goldmann appla-
nation, but shares the same difficulty with
corneas which are scarring and children
who strain or squeeze. It can be used in
those with nystagmus.
A very new portable tonometer, the iCare
tonometer (iCare, Finland) has recently
become commercially available. This
device works by a principle of measurement called “rebound”, and uses a very
small plastic-tipped probe which must be
disposed (or at least carefully cleaned)
between uses. Unlike the other tonometers, this instrument does not require the
use of anesthetic to obtain IOP measurements, since it touches the cornea (about
six times) so briefly that the average
person does not even feel it touch. This
means that the child does not have to get
eye drops for the test, thus avoiding one of
the greatest fears of children. The current
model must be used with the child in the
upright position, but the next model to be
released will not have this limitation. IOP
measurements with the iCare tonometer
are reported to be very similar to those
obtained using Tonopen in normal school
children, and most children who try it find
it more comfortable than Tonopen. The
iCare tonometry may actually some day
be suitable for home tonometry by
families of children with glaucoma, and is
currently being developed to allow selftonometry by adults with glaucoma, so
that they will have the ability to monitor
their own IOP at home.
Two additional non-portable tonometry
techniques are worth mentioning briefly.
The first, pneumatonometry, uses air
flowing across a special instrument tip, to
measure the IOP. This device is very difficult to use in the office, but can be very
useful to the ophthalmologist when the
child is under sedation or anesthesia in the
operating room, because it is able to determine the pressure even when the corneal
surface is not entirely clear or smooth. It
is not a machine that is necessary if other
means of pressure reading, as discussed
above, are available. The second technique
is often called “air-puff ” or non-contact
tonometry, because it uses a jet of air to
measure the IOP. Since air-puff tonometry does not require anesthetic or a sterile
tip (because only the air touches the front
of the eye), this technique is commonly
used as a screening test for IOP in many
eye care offices. While older air-puff
machines were not considered very
accurate, more modern devices are
reported to be similar to Goldmann
tonometry in measuring IOP.
IOP measurement in children is still
challenging, but newer technology
promises to make the task less onerous
and more pleasant for children with
glaucoma and for their ophthalmologists.
We still have much to learn about features
of a child’s cornea that affect the accuracy
of these IOP measurements, so stand by
for additional updates in future issues.
COME VISIT US AT WWW.PGCFA.ORG
The available devices for measuring IOP have increased in
number over recent years. Originally the IOP was measured by
placing a plunger-like device on the cornea, loaded with weights
of varying size, until the cornea was indented a certain amount,
and then a table was used to determine the actual IOP (depending
upon what weight was used and how far down the plunger went
as it indented the cornea). This technique, called Schiotz tonometry, is no longer recommended to measure IOP in children, due
to its inaccuracy and the difficulty performing the test on a child.
and eyepieces for the examiner). This technique is performed
after the eye receives a drop containing anesthetic as well as a
yellow dye called fluorescein. Then a blue light is used to view
the end of the tonometer tip (which contains two small prisms in
it), and the tip is pushed forward until it contacts the center of the
cornea. The patient does not feel the tonometer tip touching the
eye. The IOP is read on a dial on the slit lamp, directly in mm Hg
(read “millimeters of mercury”), the unit in which we most often
report IOP). Goldmann tonometry is an excellent technique in
older children, and cooperative children can often perform this
test by the age of about 4 years old. There is also evidence that
very abnormal central corneal thickness can affect the IOP
measured with Goldmann applanation (probably true also for all
other tonometers currently used), although the actual measured
IOP should never be adjusted but rather recorded as it was
measured. The physician can then decide if other factors might
play a role in determining the actual IOP for that given eye.
The “gold standard test” (the one considered the most dependable, and the one used most often in adults), Goldmann tonometry, is performed by placing a device against the cornea while the
child sits at the slit lamp biomicroscope (the device that the child
can put his/her head into and which is attached to a beam of light
Portable devices to measure IOP in children are often much easier
to use than Goldmann applanation, especially in those children
who are small and very active, those with nystagmus, and when a
child is under anesthesia or sedation. The Perkins tonometer is a
hand-held instrument which works in a manner very similar to
2
FACTS ABOUT
GLAUCOMA AND
CATARACTS
FIND
SUPPORT
• Join the email support group and
share information, resources and
support with other parents of children
with glaucoma and cataracts
ASK THE DOCTOR
• Ask our medical professional a question
regarding pediatric glaucoma or cataracts
QUESTIONS AND
ANSWERS
• Search our database of frequently
asked questions regarding glaucoma,
cataracts, medicine or surgery
3
NEWSLETTERS
• View or download current and past issues
• Sign up to receive a free subscription
CALENDAR OF EVENTS
WHAT’S NEW
• Significant medical articles,
most recent issue of the newsletter,
speakers notes from Annual Education Day,
video of cataract surgery
LINKS TO RELATED
WEBSITES
A Day in the Life:
A DAY IN THE LIFE OF AN
OPHTHALMOLOGY RESIDENT
By Christopher Fecarotta, MD
Ophthalmology Resident, Wills Eye Institute
Thomas Jefferson University,
Philadelphia, Pennsylvania
float peacefully on a cloud of sleep
after a long day in the Wills Eye
Emergency Room, hopeful that the
night will remain quiet and calm. Friday
nights are often difficult, with little room
for rest. I am happy to catch a few winks
in the call room. I relax as the world
begins to fade away and the day’s troubles
dissipate, when suddenly I hear a noise.
It’s a loud, irritating sound that abruptly
yanks me out of sleep and back into the
real world. Still hazy from sleep, I sit up
and when I hear the noise again, I realize
that it is the call room telephone.
I
“Hello?”
“Hi Chris, we have a patient down here for
you to see,” the night nurse answers.
“OK, I’ll be right down.”
As I hang up the phone, I look at the clock
next to the bed: 5:20 am. I get dressed,
brush my teeth, and quickly gather my
things. As I head down to the Emergency
Room, my mind rewinds to the previous
morning and the day’s events begin to run
through my head.
The day began at 7 am with Chiefs’
Rounds, where two residents (physicians
who have graduated from medical school,
completed one year of internship in a
variety of specialties and
are training to become
o p h t h a l m o l og i s t s )
present
interesting
cases to an audience of
medical students, other
residents, established
ophthalmologists,
and ophthalmology subspecialists. I
happened to be one of the presenters that
morning, and I had prepared a case of a 32
year old gentleman with blurry vision who
had an uncommon retinal disorder called
multiple evanescent white dot syndrome.
I spoke for about half an hour in front of
an audience of approximately one
hundred. Luckily, it went very well and
provided for an engaging discussion.
Afterwards, I changed from a suit into
scrubs and headed to the Wills Eye
Emergency Room, where I was in charge
of the patients that came through. Wills
Eye was founded in 1834 and is the oldest
eye hospital in the United States. It also
has one of the very few emergency rooms
in the country dedicated completely to eye
care that is open 24 hours per day, 365
days per year. Patients with complicated
eye problems are often referred from
outside physicians and sometimes travel
several hours for the specialized care we
provide.
The wide variety of pathology we see in
the Emergency Room makes Wills an
amazing place to learn eye care. We see
patients of all ages and with all types of
disease. We are also very lucky to have
some of the world’s best subspecialists
available for immediate phone consultation or on-the-spot patient evaluation, if
necessary. A typical day might include an
infant with an eye infection, a teenager
with a sports-related eye injury, an adult
with contact lens complications, or an
elderly person with acute glaucoma. As
the day began, I saw the usual smattering
of patients with itchy, dry, irritated eyes
along with a healthy portion of floaters,
blurry vision, sensitivity to light, and
eyelid styes. Before I knew it, noon had
arrived and I sat down for a quick lunch
with one of my co-residents.
The other residents at Wills are absolutely
wonderful to work with. This is not
surprising, as Wills is one of the most
coveted places to become an ophthalmology resident. While I am working in the
emergency room, most of them will be
seeing patients in the many different Wills
ophthalmology clinics; these include our
Cataract and Primary Eye Care, Cornea,
Glaucoma, Pediatrics and Ocular
Genetics, Retina, Oculoplastics, and
Ocular Oncology services. If not in the
clinic, the resident will be in the operating
room learning how to perform eye
surgery. One resident takes requests for
consultation from different medical
services at Thomas Jefferson University
Hospital who need help when their
patients have eye problems. Lectures on
different topics in ophthalmology are
scattered throughout the day and greatly
augment our learning. Our residents also
rotate through 3 other hospital sites for
additional teaching and experience. Other
learning experiences include attending
conferences, sometimes on the weekend,
participating in on-line educational activities, reading medical journal and
discussing them at “journal clubs” hosted
by our attending physician staff, doing
research projects and writing articles for
medical books and journals.
After quickly finishing up lunch, I began
seeing patients again. One of the first
patients of the afternoon is a 55 year old
woman who had a new floater in her right
eye for the previous few days. That
morning she had begun to experience
flashes of light in that eye as well, and her
vision had gotten progressively blurry as
the day progressed. I scanned her retina
very carefully at the slit lamp, looking for
any signs of disease. The optic nerve
looked very healthy, her retinal vessels
were normal, and the center of her vision
seemed unaffected. On examination of
the outer edges of her retina, however, I
noticed a small red spot in the shape of a
horseshoe: a tear in her retina. I sat down,
explained what I had found, and sent her
directly to our retina clinic, where she
would have laser treatment to prevent a
retinal detachment.
I saw a lot more patients as the day went
on, but one in particular stands out in my
mind. Around 5 o’clock pm an outside
physician called and told me he was
sending a patient in to see us. She was a
96 year old woman with an infection of
her eyelids. She arrived around 8 o’clock,
and when I saw her I immediately knew
she had more than a simple eyelid infection. She was in a tremendous amount of
pain, and part of her lower lid was black,
indicating that the tissue was dying. I
ordered a CT scan and called the oculoplastic surgeon, who specializes in the
area around the eye. When she saw the
patient, she knew exactly what had to be
The Blind Doctor –
The Jacob Bolotin
Story,
by Rosalind
Perlman
Reviewed by Andrea Scherf
‘I Do The Best I Can’
by Jacob Bolotin
“I don’t always find things easy,
And many times I foil,
When the wind’s too strong one way,
I simply change my soil.
When sorrow strikes or
bad luck hits
I do the best I can
And when I win the battle
I’m a stronger, better man.”
Book Review
he Blind Doctor is one of the most
inspirational and touching books I
have ever read. I starting reading the
book on a weekend and found the story so
moving and captivating that I couldn’t put
the book down and finished it in the same
weekend.
T
Dr. Jacob Bolotin was born in Chicago in
1888 to a poor Jewish family. One of 7
children, Jacob was the third child in the
family to be born blind. Jacob was born in
a time when all of the resources available
today as well as social attitudes towards
acceptance did not exist. Instead, a blind
person was deemed to be useless and of no
contributing value to society. Even as a
child, Jacob was determined to overcome
these prejudices and public ignorance
As a child, Jacob taught himself to train
his sense of hearing and eventually was
able to identify not only all sounds around
him, but also people by the sounds of their
footsteps. He was eventually able to
identify over two thousand patients by
odor.
By the age of fourteen, Jacob had graduated from the Illinois State School for the
Blind. Determined to not become a
burden on his struggling parents, Jacob
got a job selling brushes and then
typewriters door-to-door. He eventually
fought his way into enrolling in the
Chicago College of Medicine and graduated with honors at the age of 24, thus
becoming the world’s first totally blind
physician licensed to practice medicine.
Later he gave speeches, often up to 4 every
day for which he never charged nor
accepted compensation, while simultaneously juggling his full-time medical
practice and teaching at 3 different
medical colleges. He was a nationally
acclaimed heart and lung physician know
The world lost Dr. Bolotin far too soon; he
died in 1924 at the age of 36. Jacob
touched so many lives. Five thousand
people attended his funeral.
What Jacob achieved in his life, despite
the obstacle of being blind, is truly
amazing. Witnessing Jacob’s will to
succeed, I felt that you can’t read his story
and not feel inspired to also reach your
own goals, no matter what they may be or
what obstacles we feel may be in the path
of achieving them.
Editor’s Note: Proceeds from the book go
to the Alfred and Rosalind Perlman Trust
at Santa Barbara Foundation. This Trust
funds an annual award, the Dr. Jacob
Bolotin Award, which is to be given to the
person or organization that has made a
significant impact within the blind
community. Please go to www.nfb.org
(National Federation of the Blind) for
further information.
Paperback details:
ISBN-10: 1883423139
ISBN-13: 978-1883423131
Publisher: Blue Point Books
LARGE TYPE Edition available:
ISBN-13: 978-1-8834214-8
Audio Book details:
ISBN-13: 978-1-8834214-8
Braille Edition:
Available from Blue Point Books
(www.bluepointbooks.com)
...continued from pg 4
done. We took the patient to the procedure
room, removed a small piece of the dead
tissue, and sent it to the pathologist for
immediate evaluation. While the patient
received antibiotics, we waited anxiously
for the pathology results. Just as we had
suspected, the patient had necrotizing
fasciitis, also known as the “flesh eating
bacteria.” Her life was in danger and she
needed to go to the operating room right
away to remove all the infected tissue. I
scrambled to get her ready for the surgery,
calling all of the appropriate staff and
explaining to her and her family what
needed to be done. She was amazingly
brave and she understood that her life was
on the line. She hugged members of her
family, and as she was wheeled up to the
operating room I stood by as her family
members tried to hold back their tears.
As the hours passed, the emergency room
slowed down and I was finally able to go
up to the call room for some sleep. As my
head hit the pillow, I glanced at the clock
on the table, which read 4:00 am.
“What a day!”, I think to myself as my
flashback to the previous day’s events
comes to a close. At times, things had
seemed crazy, but it was very much a
...continued on pg 5
4
for his diagnostic prowess. He was invited
to attend a Kiwanis International convention in Toronto, Canada and became so
interested in the organization that he
successfully advocated to start the first
blind Boy Scout troop in the United States.
5
typical day in the life of a Wills Eye
ophthalmology resident. I make my way to
the emergency room and pick up the new
patient’s chart, hoping for something
simple. Instead, I read that the patient is an
eighteen year old male who was transferred from an outside hospital after taking
a bullet to his left eye. Apparently, the
bullet had lodged behind his eye and had
not hit any vital structures in the brain. In
fact, the patient had remained conscious
throughout the entire incident. I take a
deep breath and walk into his room, determined to do everything I can to save his
eye.
A Day in the Life:
A DAY IN THE LIFE OF AN
OPHTHALMOLOGY RESIDENT
By Christopher Fecarotta, MD
Ophthalmology Resident, Wills Eye Institute
Thomas Jefferson University,
Philadelphia, Pennsylvania
float peacefully on a cloud of sleep
after a long day in the Wills Eye
Emergency Room, hopeful that the
night will remain quiet and calm. Friday
nights are often difficult, with little room
for rest. I am happy to catch a few winks
in the call room. I relax as the world
begins to fade away and the day’s troubles
dissipate, when suddenly I hear a noise.
It’s a loud, irritating sound that abruptly
yanks me out of sleep and back into the
real world. Still hazy from sleep, I sit up
and when I hear the noise again, I realize
that it is the call room telephone.
I
“Hello?”
“Hi Chris, we have a patient down here for
you to see,” the night nurse answers.
“OK, I’ll be right down.”
As I hang up the phone, I look at the clock
next to the bed: 5:20 am. I get dressed,
brush my teeth, and quickly gather my
things. As I head down to the Emergency
Room, my mind rewinds to the previous
morning and the day’s events begin to run
through my head.
The day began at 7 am with Chiefs’
Rounds, where two residents (physicians
who have graduated from medical school,
completed one year of internship in a
variety of specialties and
are training to become
o p h t h a l m o l og i s t s )
present
interesting
cases to an audience of
medical students, other
residents, established
ophthalmologists,
and ophthalmology subspecialists. I
happened to be one of the presenters that
morning, and I had prepared a case of a 32
year old gentleman with blurry vision who
had an uncommon retinal disorder called
multiple evanescent white dot syndrome.
I spoke for about half an hour in front of
an audience of approximately one
hundred. Luckily, it went very well and
provided for an engaging discussion.
Afterwards, I changed from a suit into
scrubs and headed to the Wills Eye
Emergency Room, where I was in charge
of the patients that came through. Wills
Eye was founded in 1834 and is the oldest
eye hospital in the United States. It also
has one of the very few emergency rooms
in the country dedicated completely to eye
care that is open 24 hours per day, 365
days per year. Patients with complicated
eye problems are often referred from
outside physicians and sometimes travel
several hours for the specialized care we
provide.
The wide variety of pathology we see in
the Emergency Room makes Wills an
amazing place to learn eye care. We see
patients of all ages and with all types of
disease. We are also very lucky to have
some of the world’s best subspecialists
available for immediate phone consultation or on-the-spot patient evaluation, if
necessary. A typical day might include an
infant with an eye infection, a teenager
with a sports-related eye injury, an adult
with contact lens complications, or an
elderly person with acute glaucoma. As
the day began, I saw the usual smattering
of patients with itchy, dry, irritated eyes
along with a healthy portion of floaters,
blurry vision, sensitivity to light, and
eyelid styes. Before I knew it, noon had
arrived and I sat down for a quick lunch
with one of my co-residents.
The other residents at Wills are absolutely
wonderful to work with. This is not
surprising, as Wills is one of the most
coveted places to become an ophthalmology resident. While I am working in the
emergency room, most of them will be
seeing patients in the many different Wills
ophthalmology clinics; these include our
Cataract and Primary Eye Care, Cornea,
Glaucoma, Pediatrics and Ocular
Genetics, Retina, Oculoplastics, and
Ocular Oncology services. If not in the
clinic, the resident will be in the operating
room learning how to perform eye
surgery. One resident takes requests for
consultation from different medical
services at Thomas Jefferson University
Hospital who need help when their
patients have eye problems. Lectures on
different topics in ophthalmology are
scattered throughout the day and greatly
augment our learning. Our residents also
rotate through 3 other hospital sites for
additional teaching and experience. Other
learning experiences include attending
conferences, sometimes on the weekend,
participating in on-line educational activities, reading medical journal and
discussing them at “journal clubs” hosted
by our attending physician staff, doing
research projects and writing articles for
medical books and journals.
After quickly finishing up lunch, I began
seeing patients again. One of the first
patients of the afternoon is a 55 year old
woman who had a new floater in her right
eye for the previous few days. That
morning she had begun to experience
flashes of light in that eye as well, and her
vision had gotten progressively blurry as
the day progressed. I scanned her retina
very carefully at the slit lamp, looking for
any signs of disease. The optic nerve
looked very healthy, her retinal vessels
were normal, and the center of her vision
seemed unaffected. On examination of
the outer edges of her retina, however, I
noticed a small red spot in the shape of a
horseshoe: a tear in her retina. I sat down,
explained what I had found, and sent her
directly to our retina clinic, where she
would have laser treatment to prevent a
retinal detachment.
I saw a lot more patients as the day went
on, but one in particular stands out in my
mind. Around 5 o’clock pm an outside
physician called and told me he was
sending a patient in to see us. She was a
96 year old woman with an infection of
her eyelids. She arrived around 8 o’clock,
and when I saw her I immediately knew
she had more than a simple eyelid infection. She was in a tremendous amount of
pain, and part of her lower lid was black,
indicating that the tissue was dying. I
ordered a CT scan and called the oculoplastic surgeon, who specializes in the
area around the eye. When she saw the
patient, she knew exactly what had to be
The Blind Doctor –
The Jacob Bolotin
Story,
by Rosalind
Perlman
Reviewed by Andrea Scherf
‘I Do The Best I Can’
by Jacob Bolotin
“I don’t always find things easy,
And many times I foil,
When the wind’s too strong one way,
I simply change my soil.
When sorrow strikes or
bad luck hits
I do the best I can
And when I win the battle
I’m a stronger, better man.”
Book Review
he Blind Doctor is one of the most
inspirational and touching books I
have ever read. I starting reading the
book on a weekend and found the story so
moving and captivating that I couldn’t put
the book down and finished it in the same
weekend.
T
Dr. Jacob Bolotin was born in Chicago in
1888 to a poor Jewish family. One of 7
children, Jacob was the third child in the
family to be born blind. Jacob was born in
a time when all of the resources available
today as well as social attitudes towards
acceptance did not exist. Instead, a blind
person was deemed to be useless and of no
contributing value to society. Even as a
child, Jacob was determined to overcome
these prejudices and public ignorance
As a child, Jacob taught himself to train
his sense of hearing and eventually was
able to identify not only all sounds around
him, but also people by the sounds of their
footsteps. He was eventually able to
identify over two thousand patients by
odor.
By the age of fourteen, Jacob had graduated from the Illinois State School for the
Blind. Determined to not become a
burden on his struggling parents, Jacob
got a job selling brushes and then
typewriters door-to-door. He eventually
fought his way into enrolling in the
Chicago College of Medicine and graduated with honors at the age of 24, thus
becoming the world’s first totally blind
physician licensed to practice medicine.
Later he gave speeches, often up to 4 every
day for which he never charged nor
accepted compensation, while simultaneously juggling his full-time medical
practice and teaching at 3 different
medical colleges. He was a nationally
acclaimed heart and lung physician know
The world lost Dr. Bolotin far too soon; he
died in 1924 at the age of 36. Jacob
touched so many lives. Five thousand
people attended his funeral.
What Jacob achieved in his life, despite
the obstacle of being blind, is truly
amazing. Witnessing Jacob’s will to
succeed, I felt that you can’t read his story
and not feel inspired to also reach your
own goals, no matter what they may be or
what obstacles we feel may be in the path
of achieving them.
Editor’s Note: Proceeds from the book go
to the Alfred and Rosalind Perlman Trust
at Santa Barbara Foundation. This Trust
funds an annual award, the Dr. Jacob
Bolotin Award, which is to be given to the
person or organization that has made a
significant impact within the blind
community. Please go to www.nfb.org
(National Federation of the Blind) for
further information.
Paperback details:
ISBN-10: 1883423139
ISBN-13: 978-1883423131
Publisher: Blue Point Books
LARGE TYPE Edition available:
ISBN-13: 978-1-8834214-8
Audio Book details:
ISBN-13: 978-1-8834214-8
Braille Edition:
Available from Blue Point Books
(www.bluepointbooks.com)
...continued from pg 4
done. We took the patient to the procedure
room, removed a small piece of the dead
tissue, and sent it to the pathologist for
immediate evaluation. While the patient
received antibiotics, we waited anxiously
for the pathology results. Just as we had
suspected, the patient had necrotizing
fasciitis, also known as the “flesh eating
bacteria.” Her life was in danger and she
needed to go to the operating room right
away to remove all the infected tissue. I
scrambled to get her ready for the surgery,
calling all of the appropriate staff and
explaining to her and her family what
needed to be done. She was amazingly
brave and she understood that her life was
on the line. She hugged members of her
family, and as she was wheeled up to the
operating room I stood by as her family
members tried to hold back their tears.
As the hours passed, the emergency room
slowed down and I was finally able to go
up to the call room for some sleep. As my
head hit the pillow, I glanced at the clock
on the table, which read 4:00 am.
“What a day!”, I think to myself as my
flashback to the previous day’s events
comes to a close. At times, things had
seemed crazy, but it was very much a
...continued on pg 5
4
for his diagnostic prowess. He was invited
to attend a Kiwanis International convention in Toronto, Canada and became so
interested in the organization that he
successfully advocated to start the first
blind Boy Scout troop in the United States.
5
typical day in the life of a Wills Eye
ophthalmology resident. I make my way to
the emergency room and pick up the new
patient’s chart, hoping for something
simple. Instead, I read that the patient is an
eighteen year old male who was transferred from an outside hospital after taking
a bullet to his left eye. Apparently, the
bullet had lodged behind his eye and had
not hit any vital structures in the brain. In
fact, the patient had remained conscious
throughout the entire incident. I take a
deep breath and walk into his room, determined to do everything I can to save his
eye.
Accessibility To Research On Glaucoma
he PGCFA has been contacted by
The Cochrane Collaboration, an
international and well-respected
organization dedicated to assisting doctors
in providing patients with optimal care.
The Cochrane Group is looking for people
to assist them by joining their glaucoma
consumer panels and reviewing summaries
and abstracts. This is a chance for you to
ensure that the information being provided
is understandable and relevant. Please
read the article, and if you are interested in
helping, their contact information is
provided.
T
Thanks, Dave Prowten, PGCFA Chair
Katherine Twamley
Cochrane Eyes & Vision Group
London School of Hygiene &
Tropical Medicine
“I am determined that no matter how
much I trust my treating doctors, I want to
be assured that the decisions we make
together are based on as much evidence as
is in existence at the time. I believe that is
my fundamental right, and a right of
others in a similar situation.”
Review authors are specialists in their
field. They generally consider a question
for a review because of their own experiences as a provider of health care in a clinical environment or through healthcare
research and discussions. But consumers
(health care users and carers) can make an
important contribution to reviews, ensuring that the study is both relevant and
accessible to the very people who require
health care.
In other Cochrane groups consumers have
worked successfully with researchers,
participating in various different ways
from translating to ‘hand searching’
relevant studies for a review. Below is a
testimony from Silvana Simi explaining
why she joined the Cochrane Multiple
Sclerosis Consumer Group. Her daughter
has multiple sclerosis.
“I have always been convinced, even
before my daughter’s illness, that
medicine must be a patient-centred discipline, that patients must be involved in
every decision regarding their health care,
that the health care system has to provide
the proper knowledge to enable patients to
make an informed decision and consent.
My daughter’s illness has been a strong
incentive to deepen these topics and it has
been a great surprise for me to realise that
there are committed people sharing these
ideas and who are organised as an international association such as the Cochrane
Collaboration.”
CEVG is currently recruiting members of
the public to join our consumer panel on
Glaucoma. One of the key ways which
consumers have participated in other
groups is by reviewing the summaries and
abstracts of systematic reviews. Generally
one summary is sent out each month and
each summary takes less than half an hour
to read and comment to the editors.
However, the level of participation and
how consumers would like to input into
reviews is very much dependant on
the group. Find out more by
contacting CEVG or checking out the
Cochrane Consumer Network website
(http://www.cochrane.org/consumers/hom
epage.htm).
CAN YOU HELP?
Other people have joined consumer panels
to gain more competence and knowledge
around healthcare and some to ‘educate’
the experts. Whatever their reasons for
participating, they make a valuable contribution to our work.
Do you, or one of your relatives or
friends, have Glaucoma?
If so, you may be able to
communicate important
information about treatments and
rehabilitation to people
around the world.
If you would like to get involved
and help spread the word about
which treatments prevent visual
loss or alleviate its effects
(and which don’t) please email
Katherine Twamley at
katherine.twamley@lshtm.ac.uk.
Further information about the
Cochrane Eyes and Vision Group
can be found at
www.cochraneeyes.org.
mation and support to families affected by
pediatric glaucoma and cataracts all over
the world. What a powerful and heartwarming way to leave your legacy!
You can also donate shares or mutual funds
which have accrued substantial capital
gains. This way, you will not have to pay
any taxes on the capital gains.
Ray Mistry, CMA, CFP
Doing a Bequest is also a great idea.
hile you are still on planet Earth,
it is always a good idea to share
your good fortune and what you
have with others. Any donation you make to
the PGCFA helps with our educational and
community outreach activities. Remember
the PGCFA is a volunteer-based charity that
strives to provide support, resource, infor-
Leaving a gift to PGCFA in your Will is one
of the simplest ways of making a significant
donation to the PGCFA. You can bequeath a
stated dollar amount or a percentage of your
Estate. Not only does this help the PGCFA
and the families it serves, but it also lowers
or eliminates your estate’s taxes owing at
death.
As with any strategies involving your
personal finances, we always recommend
that you discuss your planned giving wishes
with your accountant and legal advisors.
Chris Silagy, founding Director of the
Australasian Cochrane Centre (1994 to
2001)
The Cochrane Collaboration is an international, not-for-profit organisation which
provides up-to-date information about the
effects of health care. We at the Cochrane
Eyes and Vision Group (CEVG) specialise
in systematic reviews of research related to
eye health. These reviews are recognised
as one of the best ways to bring together
the multitude of evidence from medical
trials, helping to frame ‘best practice’ for
doctors and patients.
Bequests and
Charitable Giving
W
6
If you wish to discuss any of these options
with a member of the PGCFA, please feel
free to call us at (416) 444-4536 or send us
an email at info@pgcfa.org and we would
be happy to discuss your wishes and
arrangements with you.
Eye on the Medical Literature
Wilder RT, et al:
Early exposure to
anesthesia and learning disabilities in a
population-based birth
cohort. Anesthesiology
2009;110:796-804
Reviewed by
Alex V. Levin, MD, MHSc, FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology and Ocular
Genetics
Wills Eye Institute
Thomas Jefferson University
any parents worry that there will
be an adverse effect of anesthesia
on their children. This is particularly true for children at risk for or with
glaucoma who require multiple general
anesthetics for periodic examinations to
determine of glaucoma is present or to
monitor treatment. It is also common for
children with glaucoma to require more
than one surgery in their lifetime.
Therefore, in addition to the concern about
the effects of one anesthesia, there is also
the concern about possible cumulative
effects from multiple times under anesthesia. This has not previously been well
studied except in immature small animal
models (e.g. baby mice) where the results
are conflicting and inconsistent between
studies.
M
These authors come from the Mayo Clinic
in Rochester, Minnesota where the general
population of the area is “captive” to a
unique longitudinal record keeping system
that allows tracking of many different
health concerns for the purpose of
research. For the purpose of this study, all
8,548 babies born from 1976 and 1982 in
five Olmsted County townships in
Minnesota, comprising a single school
district, who remained in that area up to
their 5th birthday, had their medical
records and public and/or private school
records examined along with records of
the only private tutoring agency in the
community. The aim was to identify any
child who was said to have any type of
learning disability (reading, writing, or
math) and then see if they had been
exposed to anesthesia for any reason
before their 4th birthday and if so, how
many times. Although a broad definition
of learning disability was used, children
with severe retardation were excluded.
Of 5,357 children eligible for the study,
593 had a general anesthetic, of which
75.7% had one anesthetic, 16.9% had two
episodes of anesthesia, 5.2% had 3-4,
1.3% and 5-9, and 0.8% has more than 10.
The average length of the anesthetic was
125 minutes although there was a wide
range from very short procedures to much
longer procedures. Most commonly the
anesthetic was about 75 minutes. Of the
5,357 children, 932 developed learning
disability before 19 years old. The risk of
learning disability was not increased by
one exposure to general anesthesia but the
incidence of learning disability was about
15% higher in children (an elevation of
risk by 1.6 times for 2 anesthetics and 2.6
times for 3 or more anesthetics) who had
more than one episode of anesthesia and
those in which the length of any single
anesthesia event was longer. The increase
in risk was independent of the severity of
the medical illness that was the reason for
the anesthesia. The increased risk was the
same whether the exposure to anesthesia
occurred before 2 years old or between 24 years old.
At first glance, this research may be very
troubling for the parent of a child with
glaucoma. One must carefully analyze
these findings to understand that the “jury
is still out” on this issue. Firstly, showing
an association between repeated or longer
anesthesia before 4 years old and learning
disability does not prove a cause and effect
relationship. By allowing any child to be
labeled as learning disability at any time
before their 19th birthday means that there
are more than 15 years worth of other
exposures and events that may have
contributed. In addition, we know today
that genetics play a very important role in
learning disability, especially dyslexia.
Firstly this means that some children are
predetermined to be learning disabled
regardless of such exposures. In addition,
it raises the possibility that some of the
medical conditions that required anesthesia could be genetically linked to the
learning disability such that the outcome
was entirely independent of the anesthesia.
In fact, many of these children had serious
medical issues which independently could
contribute to learning problems such as
prematurity, cancer, cerebral palsy, SturgeWeber syndrome, heart disease and other
genetic syndromes.
7
Likewise, living with chronic disease in
general, the very diseases like glaucoma
which make a child generally well but
otherwise exposed to multiple anesthetics,
or may have specific impact on the senses
required for learning such as vision, may
in of itself have an adverse impact on
education and learning abilities independent of the anesthetic exposures.
There are other problems with the study
that need to be considered. Children with
glaucoma made up a very small subset
(only two children) of the group studied by
these authors. Almost all of the children in
this study had the same anesthetics
(halothane and nitrous oxide) which
means that any conclusions, if any, are
only relevant to those drugs and in fact,
halothane is often avoided in anesthesia
for children with glaucoma because in can
cause a false lowering of the measured eye
pressure. More recent drugs tend to be
used more commonly. The study population was largely white and middle-class
limiting our ability to generalize the
results to other communities where the
rates of learning disability may be higher
or lower. Family and socioeconomic
factors clearly impact the incidence of
learning disability.
In summary I will quote the authors
themselves who write “These data cannot
reveal whether exposure to anesthesia
itself may contribute to” learning disability. Until more evidence some in, children
at risk for or with glaucoma who can not
be examined awake must continue to have
examinations under sedation or general
anesthesia as needed to ensure glaucoma
is recognized early and well controlled.
Let’s not “throw out the baby with the
bathwater” but rather ensure that we
prevent the blindness that can result from
failing to properly evaluate these children.
Accessibility To Research On Glaucoma
he PGCFA has been contacted by
The Cochrane Collaboration, an
international and well-respected
organization dedicated to assisting doctors
in providing patients with optimal care.
The Cochrane Group is looking for people
to assist them by joining their glaucoma
consumer panels and reviewing summaries
and abstracts. This is a chance for you to
ensure that the information being provided
is understandable and relevant. Please
read the article, and if you are interested in
helping, their contact information is
provided.
T
Thanks, Dave Prowten, PGCFA Chair
Katherine Twamley
Cochrane Eyes & Vision Group
London School of Hygiene &
Tropical Medicine
“I am determined that no matter how
much I trust my treating doctors, I want to
be assured that the decisions we make
together are based on as much evidence as
is in existence at the time. I believe that is
my fundamental right, and a right of
others in a similar situation.”
Review authors are specialists in their
field. They generally consider a question
for a review because of their own experiences as a provider of health care in a clinical environment or through healthcare
research and discussions. But consumers
(health care users and carers) can make an
important contribution to reviews, ensuring that the study is both relevant and
accessible to the very people who require
health care.
In other Cochrane groups consumers have
worked successfully with researchers,
participating in various different ways
from translating to ‘hand searching’
relevant studies for a review. Below is a
testimony from Silvana Simi explaining
why she joined the Cochrane Multiple
Sclerosis Consumer Group. Her daughter
has multiple sclerosis.
“I have always been convinced, even
before my daughter’s illness, that
medicine must be a patient-centred discipline, that patients must be involved in
every decision regarding their health care,
that the health care system has to provide
the proper knowledge to enable patients to
make an informed decision and consent.
My daughter’s illness has been a strong
incentive to deepen these topics and it has
been a great surprise for me to realise that
there are committed people sharing these
ideas and who are organised as an international association such as the Cochrane
Collaboration.”
CEVG is currently recruiting members of
the public to join our consumer panel on
Glaucoma. One of the key ways which
consumers have participated in other
groups is by reviewing the summaries and
abstracts of systematic reviews. Generally
one summary is sent out each month and
each summary takes less than half an hour
to read and comment to the editors.
However, the level of participation and
how consumers would like to input into
reviews is very much dependant on
the group. Find out more by
contacting CEVG or checking out the
Cochrane Consumer Network website
(http://www.cochrane.org/consumers/hom
epage.htm).
CAN YOU HELP?
Other people have joined consumer panels
to gain more competence and knowledge
around healthcare and some to ‘educate’
the experts. Whatever their reasons for
participating, they make a valuable contribution to our work.
Do you, or one of your relatives or
friends, have Glaucoma?
If so, you may be able to
communicate important
information about treatments and
rehabilitation to people
around the world.
If you would like to get involved
and help spread the word about
which treatments prevent visual
loss or alleviate its effects
(and which don’t) please email
Katherine Twamley at
katherine.twamley@lshtm.ac.uk.
Further information about the
Cochrane Eyes and Vision Group
can be found at
www.cochraneeyes.org.
mation and support to families affected by
pediatric glaucoma and cataracts all over
the world. What a powerful and heartwarming way to leave your legacy!
You can also donate shares or mutual funds
which have accrued substantial capital
gains. This way, you will not have to pay
any taxes on the capital gains.
Ray Mistry, CMA, CFP
Doing a Bequest is also a great idea.
hile you are still on planet Earth,
it is always a good idea to share
your good fortune and what you
have with others. Any donation you make to
the PGCFA helps with our educational and
community outreach activities. Remember
the PGCFA is a volunteer-based charity that
strives to provide support, resource, infor-
Leaving a gift to PGCFA in your Will is one
of the simplest ways of making a significant
donation to the PGCFA. You can bequeath a
stated dollar amount or a percentage of your
Estate. Not only does this help the PGCFA
and the families it serves, but it also lowers
or eliminates your estate’s taxes owing at
death.
As with any strategies involving your
personal finances, we always recommend
that you discuss your planned giving wishes
with your accountant and legal advisors.
Chris Silagy, founding Director of the
Australasian Cochrane Centre (1994 to
2001)
The Cochrane Collaboration is an international, not-for-profit organisation which
provides up-to-date information about the
effects of health care. We at the Cochrane
Eyes and Vision Group (CEVG) specialise
in systematic reviews of research related to
eye health. These reviews are recognised
as one of the best ways to bring together
the multitude of evidence from medical
trials, helping to frame ‘best practice’ for
doctors and patients.
Bequests and
Charitable Giving
W
6
If you wish to discuss any of these options
with a member of the PGCFA, please feel
free to call us at (416) 444-4536 or send us
an email at info@pgcfa.org and we would
be happy to discuss your wishes and
arrangements with you.
Eye on the Medical Literature
Wilder RT, et al:
Early exposure to
anesthesia and learning disabilities in a
population-based birth
cohort. Anesthesiology
2009;110:796-804
Reviewed by
Alex V. Levin, MD, MHSc, FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology and Ocular
Genetics
Wills Eye Institute
Thomas Jefferson University
any parents worry that there will
be an adverse effect of anesthesia
on their children. This is particularly true for children at risk for or with
glaucoma who require multiple general
anesthetics for periodic examinations to
determine of glaucoma is present or to
monitor treatment. It is also common for
children with glaucoma to require more
than one surgery in their lifetime.
Therefore, in addition to the concern about
the effects of one anesthesia, there is also
the concern about possible cumulative
effects from multiple times under anesthesia. This has not previously been well
studied except in immature small animal
models (e.g. baby mice) where the results
are conflicting and inconsistent between
studies.
M
These authors come from the Mayo Clinic
in Rochester, Minnesota where the general
population of the area is “captive” to a
unique longitudinal record keeping system
that allows tracking of many different
health concerns for the purpose of
research. For the purpose of this study, all
8,548 babies born from 1976 and 1982 in
five Olmsted County townships in
Minnesota, comprising a single school
district, who remained in that area up to
their 5th birthday, had their medical
records and public and/or private school
records examined along with records of
the only private tutoring agency in the
community. The aim was to identify any
child who was said to have any type of
learning disability (reading, writing, or
math) and then see if they had been
exposed to anesthesia for any reason
before their 4th birthday and if so, how
many times. Although a broad definition
of learning disability was used, children
with severe retardation were excluded.
Of 5,357 children eligible for the study,
593 had a general anesthetic, of which
75.7% had one anesthetic, 16.9% had two
episodes of anesthesia, 5.2% had 3-4,
1.3% and 5-9, and 0.8% has more than 10.
The average length of the anesthetic was
125 minutes although there was a wide
range from very short procedures to much
longer procedures. Most commonly the
anesthetic was about 75 minutes. Of the
5,357 children, 932 developed learning
disability before 19 years old. The risk of
learning disability was not increased by
one exposure to general anesthesia but the
incidence of learning disability was about
15% higher in children (an elevation of
risk by 1.6 times for 2 anesthetics and 2.6
times for 3 or more anesthetics) who had
more than one episode of anesthesia and
those in which the length of any single
anesthesia event was longer. The increase
in risk was independent of the severity of
the medical illness that was the reason for
the anesthesia. The increased risk was the
same whether the exposure to anesthesia
occurred before 2 years old or between 24 years old.
At first glance, this research may be very
troubling for the parent of a child with
glaucoma. One must carefully analyze
these findings to understand that the “jury
is still out” on this issue. Firstly, showing
an association between repeated or longer
anesthesia before 4 years old and learning
disability does not prove a cause and effect
relationship. By allowing any child to be
labeled as learning disability at any time
before their 19th birthday means that there
are more than 15 years worth of other
exposures and events that may have
contributed. In addition, we know today
that genetics play a very important role in
learning disability, especially dyslexia.
Firstly this means that some children are
predetermined to be learning disabled
regardless of such exposures. In addition,
it raises the possibility that some of the
medical conditions that required anesthesia could be genetically linked to the
learning disability such that the outcome
was entirely independent of the anesthesia.
In fact, many of these children had serious
medical issues which independently could
contribute to learning problems such as
prematurity, cancer, cerebral palsy, SturgeWeber syndrome, heart disease and other
genetic syndromes.
7
Likewise, living with chronic disease in
general, the very diseases like glaucoma
which make a child generally well but
otherwise exposed to multiple anesthetics,
or may have specific impact on the senses
required for learning such as vision, may
in of itself have an adverse impact on
education and learning abilities independent of the anesthetic exposures.
There are other problems with the study
that need to be considered. Children with
glaucoma made up a very small subset
(only two children) of the group studied by
these authors. Almost all of the children in
this study had the same anesthetics
(halothane and nitrous oxide) which
means that any conclusions, if any, are
only relevant to those drugs and in fact,
halothane is often avoided in anesthesia
for children with glaucoma because in can
cause a false lowering of the measured eye
pressure. More recent drugs tend to be
used more commonly. The study population was largely white and middle-class
limiting our ability to generalize the
results to other communities where the
rates of learning disability may be higher
or lower. Family and socioeconomic
factors clearly impact the incidence of
learning disability.
In summary I will quote the authors
themselves who write “These data cannot
reveal whether exposure to anesthesia
itself may contribute to” learning disability. Until more evidence some in, children
at risk for or with glaucoma who can not
be examined awake must continue to have
examinations under sedation or general
anesthesia as needed to ensure glaucoma
is recognized early and well controlled.
Let’s not “throw out the baby with the
bathwater” but rather ensure that we
prevent the blindness that can result from
failing to properly evaluate these children.
Navigating the Education System
What Is A Secondary Cataract
And How Soon Does It Happen After Surgery?
By Carol Farrenkopf, Ed.D.
Toronto District School Board, Vision Program Coordinator
f your child has
recently
been
diagnosed with a
visual impairment, you
may
have
many
questions regarding
how to get support within
your school system. The following series
of questions outlines a strategy to help you
navigate the education system.
I
How do you get vision-related
help for your child in school?
• Speak with someone at your child’s
school (e.g., teacher, principal, special
education teacher) to find out what
services/supports are available in the
school system for children who are
visually impaired
• Share information regarding your child’s
eye condition with the teacher (e.g.,
drops, patching schedule, medication)
What’s typically needed for a
referral for vision services in a
school district?
• Copy of an eye report or some other
medical documentation regarding the
nature of the eye condition; include
visual acuities whenever possible.
(Don’t forget to keep a copy of all
medical and educational reports for your
own files)
• Signed consent by the family to have an
assessment conducted by the appropriate
school department
• Release form allowing vision services
personnel to discuss the eye condition
with medical personnel
What types of assessments might
be expected as part of the referral/in-take process?
• Functional Vision Assessment (FVA) is
an assessment typically conducted by a
teacher or vision professional who holds
specialized qualifications as a Teacher of
Students who are Visually Impaired
(TVI). The FVA determines how your
child uses his/her vision to complete
school-related tasks. The FVA is usually
done in the school (or in the
home/preschool if the student has not yet
entered the school system) in “typical”
lighting conditions and uses classroom
materials in addition to specific assessment items
• Functional Tactile Assessment (FTA) is
an assessment that determines how your
child uses his/her tactile and auditory
senses to gather information about the
school environment. This type of
assessment is typically conducted by the
TVI with children who are functionally
blind
• Where appropriate, Orientation &
Mobility (O&M) Assessment is
conducted by a person who holds special
certification as an “O&M Specialist”.
The O&M includes learning how to
move as independently as possible
through space, with or without the use of
a white cane or other mobility tool
What happens after my child has
been assessed?
• Usually, a level of support will be
recommended:
direct instruction,
program support, monitor/ consultation,
or no support
• Some school districts require an
“official” meeting to identify the child
as being visually impaired prior to
getting vision support in the classroom.
Some school districts may provide
support without the formal identification of being visually impaired. Each
province/state has a different term for
this “official” meeting; therefore, it’s
important that you know how your
particular school district works
Does my child need an “IEP”
(Individual Education Plan)?
• Typically, if your child receives “direct
instruction” or weekly support by the
TVI and/or O&M Specialist, an IEP will
need to be developed by the classroom
teacher in conjunction with the TVI
and/or O&M Specialist
• The IEP will outline accommodations
for your child that will enable him/her to
access the school curriculum. It will
also outline specific goals related to the
Expanded Core Curriculum (ECC)
What is the ECC (Expanded
Core Curriculum)?
• The ECC relates to essential skills that
students who are visually impaired
should learn to become as independent
as possible. There are nine areas of the
ECC:
8
• Compensatory Skills (e.g., communication skills, braille, listening, speaking)
• O&M Skills (with and without a white
cane or dog guide)
• Social Interaction Skills (to prevent
social isolation)
• Independent Living Skills (personal
grooming, time management)
• Recreation & Leisure Skills
• Visual Efficiency Skills (use of optical/
non-optical aids, environmental cues)
• Assistive Technology (e.g., video magnifier/CCTV, Screen Enlargement, Voice
Output)
• Career Education (learning how to be
competitive in the world of work)
• Self-Determination
Skills
(selfadvocacy)
What are the placement choices
for my child if the visual impairment is the only disability my
child has?
By Alex V. Levin, M.D., MHSc
Chief, Pediatric Ophthalmology and
Ocular Genetics
Wills Eye Institute
Thomas Jefferson University
ataract surgery involves the removal
of the entire lens of the eye. Once
the lens is removed, another cataract
cannot form since a cataract is an opacity
in that lens. Therefore, the term “secondary cataract” is a misnomer. It refers to the
formation of scar tissue or the proliferation
of residual lens cells after surgery.
C
The lens lives inside a membrane capsule,
often referred to as “the bag”. The front
surface of the capsule is opened to allow
the surgeon access to the lens for removal
during cataract surgery. Depending on the
age of the child, the back part of the
capsule (posterior capsule) may also have a
hole cut in its center. Almost always, at
least some remnants of the capsule are left
behind. The residual capsule may opacify
over time to create a membrane, mistakenly referred to by some as a “secondary
cataract”. If this occurs, the cloudy
membrane can be opened either with the
use of a laser (YAG laser) in older
children, or surgically in younger children.
The formation of a membrane can also
occur from normal scar tissue as the eye
heals inside. This is aided by the fact that
the vitreous gel which fills the back of the
eye behind the lens is well formed in
children and can serve as a scaffold for the
proliferation of scar tissue cells along its
service thus blocking the vision.
that are left behind can sometimes grow
creating abnormal pieces of lens-like
material called “pearls”. Pearls can also
proliferate to the point where they block
the vision and therefore need to be
removed surgically. Sometimes this
complication is also referred to as a
“secondary cataract”.
When the lens is removed, especially in
children, it is almost impossible to remove
every single cell. These microscopic cells
They are “natural” events that sometimes
occur in the childhood eye following
cataract surgery.
In children, unlike adults, the formation of
pearls is more abundant and the formation
of capsule opacification more dramatic.
The latter also occurs more quickly in
young children and can even be seen
within weeks of surgery. These events are
not uncommon and occur sometimes
regardless of the skill of the surgeon or the
quality of the surgery.
Tax Saving Ideas for the Visually Impaired: T2201
• Regular classroom with Itinerant Vision
Teacher Support (support focuses on
relevant aspects of the ECC as well as
accommodations to the curriculum
within the regular classroom setting)
• Resource classroom with some integration (support related to the ECC
typically takes place in the specialized
resource room; integration into the
regular classroom with accommodations
takes place at various times during the
school day)
• Residential or day program at a specialized school for students who are visually
impaired (ECC skills taught throughout
the day, every day; “regular” subject
areas taught by TVIs)
anada
Revenue
Agency
(CRA) has a Disability Tax
Credit (T2201) which allows an
individual (in Canada) to claim a credit of
$11,116 (2008 Ontario rates) if you are under
the age of 18 (and $7,021 over age 18) on your
annual personal income tax filing. This credit
amounts to around $2,300 and $1,400 respectively in
tax refunds. No benefits will accrue if you don’t pay any
taxes.
What can I do as a parent to help
the school and my child work
together to meet his needs?
Individuals who have a severe and prolonged impairment
in physical or mental functions (and the definition has been
extended widely over the years) can claim this credit.
• Engage in frequent and open bi-directional communication
• Share information with the school as
necessary
• Provide input in your child’s educational
programming
• Involve outside agencies as needed
For visual impairment, CRA considers a patient blind even
with the use of corrective lenses or medication when:
Visual acuity in both eyes has been measured to be
20/200 (6/60) or less with the Snellen Chart (or an
equivalent); or the greatest diameter of the field of
vision in both eyes is 20 degrees or less.
By Ray Mistry, CMA, CFP
CRA website (www.cra.gc.ca - type T2201 on the search button)
and give it to your ophthalmologist to complete their portion of
the form. The ophthalmologist will sign off if he/she thinks you
are eligible. If you are a borderline claim, let the CRA decide if
you are eligible. You can also phone CRA at 1-800-959-2221 to
order the form.
C
Usually the claim for a child, who typically has no income, can be
transferred to a supporting parent. If the credit is unused in the
case of a married individual, it can be transferred to a spouse. For
parents who cannot utilize this deduction, they can transfer it to a
supporting son/daughter.
If the visual impairment started at birth or later on, and the
ophthalmologist specifies the date of onset, CRA will inform you
to go back all the previous years up to ten years, and make the
claim.
Tax benefits in Canada are designed to offset some of the
additional expenses incurred for the medically challenged.
If you have any questions, please feel free to contact me via email
at: ray@moneycare.ca.
Editor’s Note: Those living outside of Canada should check with
their own government tax agencies for similar credits.
So, if you or your child has any level of visual
impairment, and you wish to claim this annual
credit, please print the T2201 form from the
9
Navigating the Education System
What Is A Secondary Cataract
And How Soon Does It Happen After Surgery?
By Carol Farrenkopf, Ed.D.
Toronto District School Board, Vision Program Coordinator
f your child has
recently
been
diagnosed with a
visual impairment, you
may
have
many
questions regarding
how to get support within
your school system. The following series
of questions outlines a strategy to help you
navigate the education system.
I
How do you get vision-related
help for your child in school?
• Speak with someone at your child’s
school (e.g., teacher, principal, special
education teacher) to find out what
services/supports are available in the
school system for children who are
visually impaired
• Share information regarding your child’s
eye condition with the teacher (e.g.,
drops, patching schedule, medication)
What’s typically needed for a
referral for vision services in a
school district?
• Copy of an eye report or some other
medical documentation regarding the
nature of the eye condition; include
visual acuities whenever possible.
(Don’t forget to keep a copy of all
medical and educational reports for your
own files)
• Signed consent by the family to have an
assessment conducted by the appropriate
school department
• Release form allowing vision services
personnel to discuss the eye condition
with medical personnel
What types of assessments might
be expected as part of the referral/in-take process?
• Functional Vision Assessment (FVA) is
an assessment typically conducted by a
teacher or vision professional who holds
specialized qualifications as a Teacher of
Students who are Visually Impaired
(TVI). The FVA determines how your
child uses his/her vision to complete
school-related tasks. The FVA is usually
done in the school (or in the
home/preschool if the student has not yet
entered the school system) in “typical”
lighting conditions and uses classroom
materials in addition to specific assessment items
• Functional Tactile Assessment (FTA) is
an assessment that determines how your
child uses his/her tactile and auditory
senses to gather information about the
school environment. This type of
assessment is typically conducted by the
TVI with children who are functionally
blind
• Where appropriate, Orientation &
Mobility (O&M) Assessment is
conducted by a person who holds special
certification as an “O&M Specialist”.
The O&M includes learning how to
move as independently as possible
through space, with or without the use of
a white cane or other mobility tool
What happens after my child has
been assessed?
• Usually, a level of support will be
recommended:
direct instruction,
program support, monitor/ consultation,
or no support
• Some school districts require an
“official” meeting to identify the child
as being visually impaired prior to
getting vision support in the classroom.
Some school districts may provide
support without the formal identification of being visually impaired. Each
province/state has a different term for
this “official” meeting; therefore, it’s
important that you know how your
particular school district works
Does my child need an “IEP”
(Individual Education Plan)?
• Typically, if your child receives “direct
instruction” or weekly support by the
TVI and/or O&M Specialist, an IEP will
need to be developed by the classroom
teacher in conjunction with the TVI
and/or O&M Specialist
• The IEP will outline accommodations
for your child that will enable him/her to
access the school curriculum. It will
also outline specific goals related to the
Expanded Core Curriculum (ECC)
What is the ECC (Expanded
Core Curriculum)?
• The ECC relates to essential skills that
students who are visually impaired
should learn to become as independent
as possible. There are nine areas of the
ECC:
8
• Compensatory Skills (e.g., communication skills, braille, listening, speaking)
• O&M Skills (with and without a white
cane or dog guide)
• Social Interaction Skills (to prevent
social isolation)
• Independent Living Skills (personal
grooming, time management)
• Recreation & Leisure Skills
• Visual Efficiency Skills (use of optical/
non-optical aids, environmental cues)
• Assistive Technology (e.g., video magnifier/CCTV, Screen Enlargement, Voice
Output)
• Career Education (learning how to be
competitive in the world of work)
• Self-Determination
Skills
(selfadvocacy)
What are the placement choices
for my child if the visual impairment is the only disability my
child has?
By Alex V. Levin, M.D., MHSc
Chief, Pediatric Ophthalmology and
Ocular Genetics
Wills Eye Institute
Thomas Jefferson University
ataract surgery involves the removal
of the entire lens of the eye. Once
the lens is removed, another cataract
cannot form since a cataract is an opacity
in that lens. Therefore, the term “secondary cataract” is a misnomer. It refers to the
formation of scar tissue or the proliferation
of residual lens cells after surgery.
C
The lens lives inside a membrane capsule,
often referred to as “the bag”. The front
surface of the capsule is opened to allow
the surgeon access to the lens for removal
during cataract surgery. Depending on the
age of the child, the back part of the
capsule (posterior capsule) may also have a
hole cut in its center. Almost always, at
least some remnants of the capsule are left
behind. The residual capsule may opacify
over time to create a membrane, mistakenly referred to by some as a “secondary
cataract”. If this occurs, the cloudy
membrane can be opened either with the
use of a laser (YAG laser) in older
children, or surgically in younger children.
The formation of a membrane can also
occur from normal scar tissue as the eye
heals inside. This is aided by the fact that
the vitreous gel which fills the back of the
eye behind the lens is well formed in
children and can serve as a scaffold for the
proliferation of scar tissue cells along its
service thus blocking the vision.
that are left behind can sometimes grow
creating abnormal pieces of lens-like
material called “pearls”. Pearls can also
proliferate to the point where they block
the vision and therefore need to be
removed surgically. Sometimes this
complication is also referred to as a
“secondary cataract”.
When the lens is removed, especially in
children, it is almost impossible to remove
every single cell. These microscopic cells
They are “natural” events that sometimes
occur in the childhood eye following
cataract surgery.
In children, unlike adults, the formation of
pearls is more abundant and the formation
of capsule opacification more dramatic.
The latter also occurs more quickly in
young children and can even be seen
within weeks of surgery. These events are
not uncommon and occur sometimes
regardless of the skill of the surgeon or the
quality of the surgery.
Tax Saving Ideas for the Visually Impaired: T2201
• Regular classroom with Itinerant Vision
Teacher Support (support focuses on
relevant aspects of the ECC as well as
accommodations to the curriculum
within the regular classroom setting)
• Resource classroom with some integration (support related to the ECC
typically takes place in the specialized
resource room; integration into the
regular classroom with accommodations
takes place at various times during the
school day)
• Residential or day program at a specialized school for students who are visually
impaired (ECC skills taught throughout
the day, every day; “regular” subject
areas taught by TVIs)
anada
Revenue
Agency
(CRA) has a Disability Tax
Credit (T2201) which allows an
individual (in Canada) to claim a credit of
$11,116 (2008 Ontario rates) if you are under
the age of 18 (and $7,021 over age 18) on your
annual personal income tax filing. This credit
amounts to around $2,300 and $1,400 respectively in
tax refunds. No benefits will accrue if you don’t pay any
taxes.
What can I do as a parent to help
the school and my child work
together to meet his needs?
Individuals who have a severe and prolonged impairment
in physical or mental functions (and the definition has been
extended widely over the years) can claim this credit.
• Engage in frequent and open bi-directional communication
• Share information with the school as
necessary
• Provide input in your child’s educational
programming
• Involve outside agencies as needed
For visual impairment, CRA considers a patient blind even
with the use of corrective lenses or medication when:
Visual acuity in both eyes has been measured to be
20/200 (6/60) or less with the Snellen Chart (or an
equivalent); or the greatest diameter of the field of
vision in both eyes is 20 degrees or less.
By Ray Mistry, CMA, CFP
CRA website (www.cra.gc.ca - type T2201 on the search button)
and give it to your ophthalmologist to complete their portion of
the form. The ophthalmologist will sign off if he/she thinks you
are eligible. If you are a borderline claim, let the CRA decide if
you are eligible. You can also phone CRA at 1-800-959-2221 to
order the form.
C
Usually the claim for a child, who typically has no income, can be
transferred to a supporting parent. If the credit is unused in the
case of a married individual, it can be transferred to a spouse. For
parents who cannot utilize this deduction, they can transfer it to a
supporting son/daughter.
If the visual impairment started at birth or later on, and the
ophthalmologist specifies the date of onset, CRA will inform you
to go back all the previous years up to ten years, and make the
claim.
Tax benefits in Canada are designed to offset some of the
additional expenses incurred for the medically challenged.
If you have any questions, please feel free to contact me via email
at: ray@moneycare.ca.
Editor’s Note: Those living outside of Canada should check with
their own government tax agencies for similar credits.
So, if you or your child has any level of visual
impairment, and you wish to claim this annual
credit, please print the T2201 form from the
9
Family Fun Day
News from New York City
Announcement
By Andrea Osborn
By Joan Schildkraut
Welcome
Doctor Ali!
I am very pleased to announce that the PGCFA has a new member on our Scientific Advisory Board.
We are very fortunate that he has agreed to join us.
he New York City Chapter of the PGCFA held its first
Family Fun Day this past July. It was an afternoon of fun,
food and festivities! There were various games for the
children to play, arts and crafts and of course, food. The afternoon was a perfect opportunity for families to meet and ask
questions, as well as a time for the children to play together.
Those who attended came with high spirits which only added to
the enthusiasm of the day. We hope to start a tradition with the
Family Fun Day.
T
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Fundraising Report
r. Ali completed his medical
degree
and
ophthalmology
residency
training
at
the
University of Toronto. He was appointed
Chief Resident and winner of the
Wojwitka Cup for best graduating
resident. Subsequently, he completed two
fellowships at Washington University in
St. Louis, one in Pediatric Ophthalmology
and Strabismus and the other in Cornea
and External Disease, as he acquired an
interest in pediatric corneal transplantation. He is the recipient of an E.A. Baker
D
ven the smallest child can do fundraising for a special
cause. This past summer, 6 year old Bryce Sturtevant held
his very own lemonade stand. It was not to raise money for
a Star Wars figurine or new bike, but to benefit the PGCFA.
Bryce’s baby brother was diagnosed with congenital cataracts in
January. Bryce came with up with the idea and with the help of
his parents, he sat behind a small table selling lemonade on
various occasions this summer. Between the money earned from
customers and donations from friends, family and his parents’ coworkers, he raised $100.00. WAY TO GO BRYCE!
E
New York City area families enjoying Family Fun Day
Also, the NY-PGCFA is pleased to announce that we are in the
process of our third year of funding research grants. Solicitations
to over 1,500 doctors have been mailed. The research projects
will be selected and monies funded in the first quarter of 2010.
Look out for our update on the awards in the Summer 2010 issue
of the newsletter.
For more information on how you can get involved with the NYC
Chapter and be informed of what’s happening in the NYC metro
area, please check out our website at: www.nyc.pgcfa.org. Please
note that you need to sign-up separately (or in addition to the
main PGCFA site) at the NYC site to receive email notifications
specific to the NYC chapter. We look forward to meeting new
families and providing a network of support for parents and
children in the NYC area. Check us out!
Brenden Schildkraut playing
a fishing game
Brandon Lakind having
fun with a bean bag toss
THANK YOU FOR YOUR SUPPORT!!
In addition to our valued personal donors, the PGCFA
would like to acknowledge the financial support provided by its corporate donors:
Thank you for helping our children to see the sun, the moon and the stars.
To support the Pediatric Glaucoma and Cataract Family
Association, please send in your donation to our address as listed
below. Please be sure to include your mailing address so that we
may send you a charitable tax receipt. Or, to make an online
donation, please visit our website at www.pgcfa.org
10
Pediatric Glaucoma and Cataract Family Association
PO Box 144
27 St. Clair Ave. E
Toronto, ON M4T 2L7
Canada
Luna and the
BIG BLUR:
A Story for Children
Who Wear Glasses
by Shirley Day
Book Review
Fellowship awarded by the Canadian
National Institute for the Blind.
He has been on staff at The Hospital for
Sick Children in Toronto since 2006 and is
currently Director of the Fellowship
Program. He is also has the academic rank
of Assistant Professor at the University of
Toronto. His current interests include
developing novel techniques in corneal
transplantation and glaucoma surgery in
children.
Dr. David S. Walton, M.D.
Associate Clinical Professor of
Ophthalmology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
PGCFA Scientific Advisory Board:
Ken K Nischal, FRCOphth
Head of the Clinical and Academic Dept.
of Ophthalmology
Fellowship Director
Great Ormond St Hospital for Children
Hon. Senior Lecturer
Institute of Child Health
London, England
Alex V. Levin, M.D., MHSc, FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology
and Ocular Genetics
Wills Eye Hospital
Philadelphia, PA
Norm Medow, M.D.
Director of Pediatric Ophthalmology and
Strabismus at Manhattan Eye, Ear and
Throat Hospital, New York City
Sharon F. Freedman, M.D.
Professor of Ophthalmology and Pediatrics
Chief, Division of Pediatric Ophthalmology
Duke University Eye Center, Durham, NC, USA
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Reading Corner
out her own frames, but still feels that all
she can see when she looks in the mirror
are her glasses. She tries many things to
cover up her glasses or make them less
noticeable, but nothing works. She also
hates her name, thinking that her parents
have named her after tuna fish. The one
thing Luna does like, is watching the
moon in the night sky before she goes to
sleep.
One night, Luna has a dream that she is on
the moon and that she can see everything
By Maddy Osborn, age 7, unilateral aphakia
I liked this story. Luna stops wearing her
glasses because she thinks she doesn’t
need them. But then after a few funny
things happen, she realizes that she does
need them after all and things are much
better when she wears them. It was a
funny story; I really liked when she pets
her Mom’s slippers and stirs the fish bowl!
perfectly without her glasses. The next
morning, Luna does not put her glasses
on, thinking she can see without them.
But without her glasses, she bumps into
things, pets her Mom’s fuzzy slippers
instead of the cat, almost eats cat treats
instead of cookies and ends up with a
headache from straining to see without
her glasses. Luna’s father explains to her
that while wearing glasses might make her
different from some people, that there are
other things about her, like her wit, charm
and personality that make her different
also. He then also explains that she is
special because she is the only one in the
family named after something magical –
Luna, the moon goddess. Luna now
understands more about accepting who we
are and that it is ok to be different, that we
are all different in our own way.
•
•
•
•
•
Book Summary
By Andrea Osborn
Luna is a young girl who is nearsighted
but hates wearing her glasses. She picked
11
Reading level: Ages 4-8
Paperback: 32 pages
Publisher: Magination Press
ISBN-10: 1557987777
ISBN-13: 978-1557987778
Family Fun Day
News from New York City
Announcement
By Andrea Osborn
By Joan Schildkraut
Welcome
Doctor Ali!
I am very pleased to announce that the PGCFA has a new member on our Scientific Advisory Board.
We are very fortunate that he has agreed to join us.
he New York City Chapter of the PGCFA held its first
Family Fun Day this past July. It was an afternoon of fun,
food and festivities! There were various games for the
children to play, arts and crafts and of course, food. The afternoon was a perfect opportunity for families to meet and ask
questions, as well as a time for the children to play together.
Those who attended came with high spirits which only added to
the enthusiasm of the day. We hope to start a tradition with the
Family Fun Day.
T
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Fundraising Report
r. Ali completed his medical
degree
and
ophthalmology
residency
training
at
the
University of Toronto. He was appointed
Chief Resident and winner of the
Wojwitka Cup for best graduating
resident. Subsequently, he completed two
fellowships at Washington University in
St. Louis, one in Pediatric Ophthalmology
and Strabismus and the other in Cornea
and External Disease, as he acquired an
interest in pediatric corneal transplantation. He is the recipient of an E.A. Baker
D
ven the smallest child can do fundraising for a special
cause. This past summer, 6 year old Bryce Sturtevant held
his very own lemonade stand. It was not to raise money for
a Star Wars figurine or new bike, but to benefit the PGCFA.
Bryce’s baby brother was diagnosed with congenital cataracts in
January. Bryce came with up with the idea and with the help of
his parents, he sat behind a small table selling lemonade on
various occasions this summer. Between the money earned from
customers and donations from friends, family and his parents’ coworkers, he raised $100.00. WAY TO GO BRYCE!
E
New York City area families enjoying Family Fun Day
Also, the NY-PGCFA is pleased to announce that we are in the
process of our third year of funding research grants. Solicitations
to over 1,500 doctors have been mailed. The research projects
will be selected and monies funded in the first quarter of 2010.
Look out for our update on the awards in the Summer 2010 issue
of the newsletter.
For more information on how you can get involved with the NYC
Chapter and be informed of what’s happening in the NYC metro
area, please check out our website at: www.nyc.pgcfa.org. Please
note that you need to sign-up separately (or in addition to the
main PGCFA site) at the NYC site to receive email notifications
specific to the NYC chapter. We look forward to meeting new
families and providing a network of support for parents and
children in the NYC area. Check us out!
Brenden Schildkraut playing
a fishing game
Brandon Lakind having
fun with a bean bag toss
THANK YOU FOR YOUR SUPPORT!!
In addition to our valued personal donors, the PGCFA
would like to acknowledge the financial support provided by its corporate donors:
Thank you for helping our children to see the sun, the moon and the stars.
To support the Pediatric Glaucoma and Cataract Family
Association, please send in your donation to our address as listed
below. Please be sure to include your mailing address so that we
may send you a charitable tax receipt. Or, to make an online
donation, please visit our website at www.pgcfa.org
10
Pediatric Glaucoma and Cataract Family Association
PO Box 144
27 St. Clair Ave. E
Toronto, ON M4T 2L7
Canada
Luna and the
BIG BLUR:
A Story for Children
Who Wear Glasses
by Shirley Day
Book Review
Fellowship awarded by the Canadian
National Institute for the Blind.
He has been on staff at The Hospital for
Sick Children in Toronto since 2006 and is
currently Director of the Fellowship
Program. He is also has the academic rank
of Assistant Professor at the University of
Toronto. His current interests include
developing novel techniques in corneal
transplantation and glaucoma surgery in
children.
Dr. David S. Walton, M.D.
Associate Clinical Professor of
Ophthalmology
Harvard Medical School
Massachusetts Eye and Ear Infirmary
PGCFA Scientific Advisory Board:
Ken K Nischal, FRCOphth
Head of the Clinical and Academic Dept.
of Ophthalmology
Fellowship Director
Great Ormond St Hospital for Children
Hon. Senior Lecturer
Institute of Child Health
London, England
Alex V. Levin, M.D., MHSc, FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology
and Ocular Genetics
Wills Eye Hospital
Philadelphia, PA
Norm Medow, M.D.
Director of Pediatric Ophthalmology and
Strabismus at Manhattan Eye, Ear and
Throat Hospital, New York City
Sharon F. Freedman, M.D.
Professor of Ophthalmology and Pediatrics
Chief, Division of Pediatric Ophthalmology
Duke University Eye Center, Durham, NC, USA
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Reading Corner
out her own frames, but still feels that all
she can see when she looks in the mirror
are her glasses. She tries many things to
cover up her glasses or make them less
noticeable, but nothing works. She also
hates her name, thinking that her parents
have named her after tuna fish. The one
thing Luna does like, is watching the
moon in the night sky before she goes to
sleep.
One night, Luna has a dream that she is on
the moon and that she can see everything
By Maddy Osborn, age 7, unilateral aphakia
I liked this story. Luna stops wearing her
glasses because she thinks she doesn’t
need them. But then after a few funny
things happen, she realizes that she does
need them after all and things are much
better when she wears them. It was a
funny story; I really liked when she pets
her Mom’s slippers and stirs the fish bowl!
perfectly without her glasses. The next
morning, Luna does not put her glasses
on, thinking she can see without them.
But without her glasses, she bumps into
things, pets her Mom’s fuzzy slippers
instead of the cat, almost eats cat treats
instead of cookies and ends up with a
headache from straining to see without
her glasses. Luna’s father explains to her
that while wearing glasses might make her
different from some people, that there are
other things about her, like her wit, charm
and personality that make her different
also. He then also explains that she is
special because she is the only one in the
family named after something magical –
Luna, the moon goddess. Luna now
understands more about accepting who we
are and that it is ok to be different, that we
are all different in our own way.
•
•
•
•
•
Book Summary
By Andrea Osborn
Luna is a young girl who is nearsighted
but hates wearing her glasses. She picked
11
Reading level: Ages 4-8
Paperback: 32 pages
Publisher: Magination Press
ISBN-10: 1557987777
ISBN-13: 978-1557987778
Announcements
The PGCFA Needs Your Help!
Don’t forget that if you make a charitable contribution to the PGCFA you will receive
a tax receipt. Not only are you helping children and their families, you receive a
personal benefit as well.
CHANGE
OF
ADDRESS
Your contribution will ensure the PGCFA can continue to –
• provide you with important information on treatments, new and innovative research
and stories you can relate to through our website and newsletter
• host our annual Education Day
• encourage new discoveries through our research awards
Please note that the PGCFA has
recently changed its mailing
address. The new address
effective immediately is:
Here are three ways you can make a difference:
1. Direct your annual United Way pledges to the PGCFA by listing the
PGCFA’s charitable number on the back of your pledge form.
Our charitable number is: 89268 4960 RR0001.
2. Make a one-time or recurring donation on-line at www.pgcfa.org
– it’s fast, easy and secure. All major credit cards are accepted.
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
3. Mail your contribution to:
PGCFA
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
You can also email us at
info@pgcfa.org or phone us at
416-444-4536.
Your Support Will Make a Difference
The Pediatric Glaucoma and Cataract Family Association is a volunteer group, committed to promoting
the quality of life for children with glaucoma and cataracts and their families by:
• Providing information and education • Providing support
Together, we can help children see the sun, the moon and the stars.
For more information, visit our website at www.pgcfa.org
To support the Pediatric Glaucoma and Cataract Family Association, please send in your donation to our
address as listed below. Please be sure to include your mailing address so that we may send you a
charitable tax receipt. Or, to make an online donation, please visit our website at www.pgcfa.org
Canadian Charitable Registration # 89268 4960 RR0001
This is a Canadian publication.
Comments by Canadian physicians
are intended only for residents in
Canada in accordance with the
principles mentioned above.
MORINformation
Volume XVII • Issue 1
• INSIGHT INTO CHILDREN’S GLAUCOMA
In This Issue:
Pg. No.
Contact Lens Options for Infants
and Small Children After
Cataract Surgery
1
Tonometry – Measuring the
Eye’s Pressure in Children
2
A Day in the Life of an
Ophthalmology Resident
4
Book Review – The Blind Doctor
5
Accessibility to Research on Glaucoma 6
We sincerely thank you for your kind support in the past and we look forward to
your continued support in helping children see the sun, the moon and the stars.
Medical information and advice
provided by the PGCFA or physicians acting at their request, does
not represent a prescription and
should not replace the information
and advice given by your own
physicians and other medical
professionals.
Winter 2010
Scientific Advisory Board
Alex V. Levin, M.D., MHSc,
Harvard Medical School
Massachusetts Eye and
Ear Infirmary
FAAP, FAAO, FRCSC
Chief, Pediatric Ophthalmology Ken K Nischal, FRCOphth
and Ocular Genetics
Head of the Clinical and
Wills Eye Hospital
Academic Dept. of
Philadelphia, PA
Ophthalmology
Fellowship Director
Sharon F. Freedman, M.D.
Great Ormond St Hospital
Professor of Ophthalmology
for Children
and Pediatrics
Hon. Senior Lecturer
Chief, Division of Pediatric
Institute of Child Health
Ophthalmology
London, England
Duke University Eye Center,
Durham, NC, USA
Norm Medow, M.D.
Director of Pediatric
Dr. David S. Walton, M.D.
Associate Clinical Professor of Ophthalmology and Strabismus
at Manhattan Eye, Ear and
Ophthalmology
Throat Hospital, New York City
Asim Ali, M.D., FRCSC
Staff Ophthalmologist
The Hospital for Sick Children
University of Toronto
Board of Directors
Mike Atwell - Past Chair
Ron Hendrix
Ian Hubling - Webmaster
Alex Levin, MD, FRCSC –
Medical Advisor
Robert Lewis - Fundraising
Monika Mistry
Ray Mistry
Leslie Mowat - Past Chair
Andrea Osborn - Newsletter
Editor
David Prowten - Chair
Russell Schildkraut
Mike Taitz
David Van – Treasurer
Janice Vogtle
PGCFA contact details:
Website: www.pgcfa.org
Email: info@pgcfa.org
Telephone: (416) 444-4536
Postal address:
Pediatric Glaucoma and
Cataract Family Association
PO Box 144
27 St. Clair Avenue East
Toronto Ontario
M4T 2L7
Bequests and Charitable Giving
6
Eye on the Medical Literature:
Early Exposure to Anesthesia and
Learning Disabilities
7
Navigating the Education System
8
What is a Secondary Cataract?
9
Tax Savings Ideas for the
Visually Impaired
9
News from New York City
10
Announcement: New Member on
Scientific Advisory Board
11
Reading Corner: Luna and
the Big Blur
11
Thank You for Your Support!
Announcement: Change of Address
12
PGCFA Needs Your Help
12
AND
CATARACTS •
Contact Lens Options for Infants and
Small Children After Cataract Surgery
Scott A Edmonds, O.D.
Susan E. Edmonds, O.D.
Wills Eye Institute
Philadelphia PA
ataract surgery involves removal of
the natural lens of the eye. Visual
rehabilitation requires replacement
of this focusing power. Contact Lenses are
manageable for most children with strong
glasses prescriptions and provide the
excellent vision required for normal
growth and development of the visual
system. The correct development of the
brain and the neurological aspects of
vision such as acuity, contrast sensitivity,
binocularity, and depth perception all
require clear, well focused light.
C
One option is a contact lens that provides
full time vision correction, can be tolerated by the cornea for extended wear and
is easy to insert and remove when
required. After cataract surgery, the Silsoft
lens by Bausch and Lomb is a top choice
for these qualities. This lens provides
excellent oxygen for corneal health, is
easy to insert and remove and is available
“off the shelf ” for quick replacement
[Editor’s note: availability may vary in
certain parts of the world]. This lens
option however has some drawbacks: it is
the most expensive lens in the group and in
some children, it is easily ejected from the
eye and possibly lost. It also has an artificial surface coating to make it wettable
and this surface is damaged by handling
and exposure to air. Once the surface is
damaged, it attracts protein and mucous
and the lens becomes unwearable. While
some children with good tear film, blink,
and lid anatomy can tolerate the lens for
months and months, other children will
damage the surface in a matter of days thus
requiring frequent replacement.
The second option is a custom rigid gas
permeable lens. This option has been
around for a long time and has always
provided the best optics, and newer
plastics and computerized lathe techniques
are bringing it closer to the first option.
The lenses now provide plenty of oxygen,
and can be worn on a long time extended
wear basis. Each lens is custom made and
can be adjusted “in office” for an optimal
fit that minimizes ejection, moves freely
and centers correctly. The lens is a bit
harder to insert and remove in a baby or an
uncooperative child but this usually
improves over time. Since the lens has to
This publication is dedicated to the
memory of Dr. Donald Morin,
an international acclaimed expert on
pediatric glaucoma and cataracts.
Helping children see
the sun,
the moon,
and the stars.
Thanks…. to all the contributors to this edition of MORINformation.
12
www.pgcfa.org
...continued on pg 2
1