Why did you go away....

I recall Rashmi as a playful, chubby baby of one & half years age brought to my clinic sometimes in December 2000. Accompanied by her parents & few “well wishers”, she certainly looked a very quiet & disciplined child for her age. The reason for consulting me was obvious: this little girl had an anomaly over her face. Her left eye was visibly smaller than the right one ever since her birth. In addition, she was a premature child.

Unaware about the implications of this facial asymmetry, the parents were primarily concerned with its cosmetic aspect. “After all…”, said one of the well wisher of the family, “she is a girl! Who would marry her, doc sa’ab”. I requested these “uncles” to leave the room so that I could have some quality time with the parents who needed to see the problem in correct perspective with fewer distractions.

“I must examine her under anaesthesia”, I explained after having discussed the need for a proper evaluation. The smaller of the two eyes could have a significant refractive error necessitating early introduction of glasses to ensure proper functional development of her retina. Not treated this way, there would be every chance of this eye becoming “lazy” or “amblyopic” as it is called in medical jargon. The child could eventually develop a squint.

As a premature baby, she was also prone to ROP (“the retinopathy of prematurity”) , although I felt it was unlikely in this particular child.

On the day of the examination, she happily allowed to be escorted to the operation theatre in a nurse’s lap. She drew her head up curiously as the anesthetist approached her with a small scalp vein set soon to be introduced in one of her veins. As the doctor pushed it in, the child looked in utter disbelief as if trying to say “You too, Brutus!”. Minutes later, she was fast asleep under the effect of the intravenous drug.

The examination was soon over & the child was in the recovery room. The parents were explained that the child would need another visit a few days later, a set of spectacles & there after, periodic check ups.

Out of no where, turned in a “well wisher”. Agitated they indeed were, since their hapless child had not been fed since early morning.

The well wisher was annoyed as the glasses were not prescribed immediately.
“We would better take her else where!” came the decree from the well wishing uncle.

I tried to pacify the parents in vain that we already have enough information about the child, but the uncle had struck!

That was the last time I saw Rashmi.

I don’t know which centre they took the child to. The child would have been through a repeat examination under anesthesia, with more punctures in her skin.

The moral of the story for Indian attendants is as follows:

(1) Let the doctor deal!

(2) Beware of the well wishers turning in at the very last moment. They would often like to have a prominent role in the management and would like to make up for their delayed entry in the scene.

Moral for Indian doctors:

(1) Try to communicate to the parents, take them in confidence in the very beginning.

(2) If there are too many well wishers, ask the parents to decide who would be there for discussion regarding the management.

Colour blindness.... Will it affect my driving and job prospects?

A senior ophthalmologist reading my blog, brought out the fact I had missed out writing on colour blindness.

I would use this opportunity to comment on that and also include information on job and educational prospects.

In India my clinical experience says that different "RTOs" apply arbitrary criterion for driving licenses: Be it a colour blind person, a simple myope or some one else. The lack of consistency may not be unique to India, European Union and the USA & Canada all have different guidelines applicable in different regions. (The difference being that, the laws are applied in a consistent manner!).

Bulgaria allows driving licenses to colour blinds, most countries in the EC do not. In the USA, some states have legislation that treats "a new or a professional" driver differently. Most states also have "restricted licenses" as well, allowing one to drive in specified conditions that include factors such scotopic or photopic (day light or otherwise) conditions.

In India, the pattern of governance and bureaucracy is far different from what one sees in more mature democracies. I don't intend to criticize "my country" since I am sure, better information, transparency and appropriate use of the right to information will address most of the unresolved issues over a period of time.

I recall, way back in 1985, fresh through a state Pre Medical Test, I was made to go through a "fitness test". Being a myopic, I expected to be asked to read the Snellen's chart to begin with. Instead Dr. Tandon, sipping tea leisurely, asked me to hand over my glasses to him. With one eye closed, the "veteran" looked through my concave glasses and instantly decided my fitness:

I was declared "not fit" to pursue medicine! No retinal evaluation, no best corrected visual acuity! No response to my pleading either!

How did I get across that hurdle is a different story. As an ophthalmologist, I continue to see such examples of human wisdom, where these "omniscient guardians" of Indian law decide some one's fate.

Most recent one was a guy who was not allowed to enter into "fisheries" at a renowned world class univeristy. As a colour blind, I wonder if he would have problems identifying the species of fishes! When last heard, he had moved court against the discrimination.

Access to education is a basic right. Reader may find the story of a medical student from All India Institute of Medical Sciences who was not allowed to take examinations following his visual loss due to Eales' disease until the NHRC came to his rescue. (See earlier post: "Success amidst adversities").

It is amazing, that in this era, where "equal opportunity employer" is a widely used tag, such things continue to happen! There are ways to tackle such issues - the legal ones. The right to information is an easier tool than moving the court! If you are not keen to go these ways, in India you tend to use "connections" or go and pay "bribe", the panacea for all!

The choice is yours.

Returning to the basic issue: Can colour blindness affect job prospects?

Using a disclaimer that this blog is not a comprehensive source of information, I would say, there are professions such as armed forces (specially aviation), railways, etc where an individual's ability to judge colours tends to be of paramount importance and being a colour blind would make him prone to errors.

There are however plenty of work places, I feel, where a blanket restriction is not needed. A student of fisheries may go on to study something that relates to the impact of toxic waste on aquatic ecosystem if not the morphology of colourful fishes! Would you not allow such a person to even study a subject of his choice? Same applies to the blind medical student from New Delhi, who still had a great potential to be a psychiatrist! But for that he needed to obtain his bachelor's degree first!

Simply underlining that a change is needed. Who can bring about those changes best? You, if you are the one facing obstacles!

Best wishes.

Manish

Visual requirements for driving in India and elsewhere

Few months have passed since an Indian immigrant in Canada walked into my clinic. He had been denied a driving license by the Canadian authorities.

"... The guy didn't cooperate!", he said, shrugging his shoulders and looking at me furiously, as if I was the one who denied him his driving license.

"... And he didn't cite any reason either!", he continued.

I examined him thoroughly, and realized he had a normal vision but was a "Primary Open angle Glaucoma Suspect".

I explained him, "See, you need to undergo a test called automated perimetry, that will help us decide if you have a normal field of vision or not. With a normal result, you get a license, without it driving may be hazardous, and in your own self interest, you may avoid driving".

I am not sure if he was indeed seen as a glaucoma suspect in Canada, but in all probabilities they seem to be carrying out a good evaluation.

I don't know what happened to the guy, but he called me this morning and asked me if I could e mail him his glasses' diopteric power. I complied with his request and mentioned his visual status on the specified date.

That was this Canadian chap!

Another girl came to me today and told me that the local office had refused a driving license to her brother. The report suggested a best corrected visual acuity of 6/12 in one eye and 6/6 in the other eye. The visual acuity of 6/12 did not match with my record of 6/9.

Apparently, the license authority had gone by his perception about myopia; the boy had moderate myopia but could read well with his glasses. No other evaluation was carried out.

So, this is a contrasting situation: Two countries, two norms. Worst, the Indian authority in the second case didn't seem to know the realistic guidelines for determining the eligibility for getting a driving license.

There are more differences in the Vision Requirements for Driving Safety in different countries:

In Canada, the visual field requirement in Quebec may be different from other provinces. While the visual acuity requirements in India is 6/18, Canada allows a license with a visual acuity of 20/50 (equal to 6/15 in Indian proportion). But unlike Canada, India doesn't have visual field restrictions! In some countries such as U.K., visual acuity is tested if the driver declares an eye disease. Venezuelan authorites resort to routine evaluation of visual field by "confrontation" method where a person with a normal field would compare his field grossly with that of the applicant.

The requirements in the USA differ from state to state and strangely, In Indiana and in Michigan a monocular patient could be allowed with a vision of 20/50 (0.4, 6/15) whereas the requirement for binocular drivers is 20/40 (0.5, 6/12). In the USA, bi optic telescopes are allowed in some states.

So if you are in India, you would need to educate yourself and then can appeal against any odds that you might face due to the ignorance of the "system", while if you happen to be an immigrant in a country that tests the visual field, understand that safety of you as well as others depends on more factors than mere driving skills .

I sincerely hope, that the Indian authorities would soon define a criterion for visual field as well.

Happy driving!

Chronic ailment: Should I see my doctor again?

Timothy's mother stopped using her anti rheumatic drugs.

Vipul's father has been fed up with his repeated visits to the doctor, who has "very few" medicines for Vipul - so much so, that little Vipul also has their names on his tips. Smart Vipul's smart father has now graduated into "half doctor". He now administers a steroid drop every time the child begins to feel an itchy sensation in his eyes. After all even the doctor would prescribe drugs that don't seem to work ! ... or gives a medicine that seems to have every possible side effect under the sky!

Timothy's mother and Vipul's father are on two extremes.

One has "accepted" the fact that her joint pain is now "incurable" and thereby willing to accept the predicament her mother had after decades of inappropriately managed arthritis that led to permanent joint deformities.

Vipul's father has substituted for the child's doctor.

Chronic patients typically go through a cyclical path when it comes to reacting to their illnesses.

In the first phase, there often is a sense of disbelief.

.... I have been fit! The diagnosis is wrong! I need a second opinion. These characterize a "denial" mode.

Sooner or later the patient and relatives begin to reconcile. Fine, I have *%(@%$#. I need treatment and I would stick to the advice my doctor or counsellor gives.

Hereafter they feel that once on medicine, everything is going to fine and predictable in a mathematical manner. That's where they go wrong!

Human bodies do not follow an equation or a graph. Diseases typically tend to have remissions and recurrences. It's just like a journey on a high way. Sometimes you need to slow down, sometimes you accelerate. Steep slopes, sharp turns every thing is part of the journey.

So is your disease. You need to go to your doctor repeatedly, when you have a chronic ailment. The doctor on his part would decide on how frequently you need to visit him. He won't make extra bucks through those extra visits. He will change medication which may include drugs that have subtle or serious side effects. The product information leaflets are there, but can not substitute a doctor.

Changing medicine is only one aspect. Even the dosage needs to be altered. Recall your foot control over the accelerator, break or clutch of your vehicle. When you drive yourself, you have the control; when someone else does, you don't normally question his wisdom to use these controls. Do you?

So why rob the doctor of his privilege?

Let him take care of you. Trust him. Trust his abilities and trust his wisdom!

So, please come out of your slumber.

See your doctor again!

Best!