In a country which has the unenviable record of having the largest number of blind people in the world, cataract has often been cited as being most responsible for this life-crippling ocular condition. With estimates attributing 50-80% of the bilateral blindness cases in India to cataract, this must be treated as a matter of utmost and even exigent concern. In fact, cataract is also said to be the biggest cause behind what is called avoidable blindness. Globally too, cataract is the single most important cause of blindness, and the second most common cause of moderate and severe vision impairment (MSVI).
WHAT IS CATARACT?
Cataract implies an eye condition which entails clouding of the lens in the eye which could occur on account of protein in the lens breaking down and clumping together leading to a blockage and weakness in vision. If not intervened at the opportune moment, it can even cause permanent blindness. Because it develops slowly, chances of being identified earlier is slim and as such it poses a silent threat to the long-term health of our eyes. It can occur in either one or both eyes. Some of the symptoms include blurry vision, sensitivity to bright lights, frequent perception of halos and rings around light entering the eye, dim and hazy colours, double vision or diplopia, frequent changing of power for glasses and lenses etc.
THE RELATION BETWEEN AGING & CATARACT
Cataract typically is a result of aging. According to the National Blindness and Visual Impairment Survey India 2015-19, cataract is the leading cause of blindness in people above 50 years. It is behind 66.2% blindness cases, 80.7%severe visual impairment cases and 70.2 per cent moderate visual impairment cases in this age group. At the same time, cataract can also be caused by some eye disease or an injury. Importantly, some children are also congenitally cataract patients.
While cataract is purely an ocular condition, there are certain non-eye related factors that aggravate the risk of getting this disease. For instance, if you expose your eyes excessively to the sun or any radiation without protection, you risk making things worse. Or if you have been taking steroids or if you are a smoker, the risk for getting cataract increases. At the same time, some non-communicable lifestyle diseases such as diabetes can also accelerate development of cataract.
HOW DOES CATARACT IMPACT EYES?
In normal course, your vision slowly and progressively begins to weaken. Your day to day functioning of the eye increasingly becomes less efficient. If you fail to detect cataract at the right time and leave it untreated for long, it can lead to complications in the form of what is called hyper mature cataract. In this, the cortical material leaks through the capsule of the lens leaving the lens wrinkled and shrunken. This in turn, can lead to a rise in the pressures in the eye, leading to secondary glaucoma which may permanently impair vision. However, under normal circumstances, cataract surgery is performed easily without the need for patient’s admittance into the hospital and the patient can resume regular activities soon after the surgery.
MODES OF TREATMENT
In the early stages, regular eyeglasses can help. Lifestyle modification measures such as getting the room or the place better lighting, wearing anti-reflective glasses during night driving can help to a certain extent when the cataract is at an early stage of development. However, even after these measures if you are having difficulty in reading, or in driving or any regular household or official activity, you need to go for surgery. The most commonly performed surgery in the current times, particularly in the urban areas is Phacoemulsification which can be done with or without the assistance of Femtosecond Laser for added precision. A safe and low-cost alternative in the rural scenario is the Manual Small Incision Cataract Surgery (SICS). Cataract surgery is one of the most commonly performed surgeries in India.
CATARACT SURGERIES IN INDIA
Importantly, more cataract surgeries are being conducted in India than the US, Europe and China put together. According to National Health Profile 2019 issued by the Central Bureau of Health Intelligence under Ministry of Health and Family Welfare, against a target of 6.6 million cataract operations, 6.4 million operations were conducted in the year 2017-18. While UP, Gujarat and Maharashtra were states where most operations were done, at 9.48 lakh, 7.8 lakh and 6.8 lakh respectively, some of the north-eastern states and other smaller states had recorded modest number of operations.
BARRIERS TO CARE
As regards barriers to care, while cost has been one big barrier, lack of awareness is another major reason behind such high prevalence of cataract in the country. Also, poor infrastructure or non-availability of equipped operation theatre for ophthalmic microsurgery in rural and remote areas and the low presence of trained ophthalmologists in the country are other barriers to access care.
Therefore, while it is up to the healthcare authorities to improve infrastructure and mount awareness campaigns to address cataract, lay people should also be equally alert to this condition. That it is preventable and timely intervention can forestall blindness, a most debilitating life condition, must be uppermost in everyone’s minds. India has been a signatory to the World Health Organization resolution on Vision 2020 on the right to sight. We must strive to stay on the right course to meet those objectives.
Dr Tushar Grover is Medical Director, Vision Eye Centre, New Delhi.
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KILLER T CELLS MAY PROTECT US FROM NEW VARIANTS OF COVID-19
Neutralising antibodies have been a primary focus for the protection from serious disease and death from Covid-19, and the effectiveness of various vaccines. Neutralizing antibodies are also tested for their effectiveness against emerging mutant strains of SARS-CoV-2 (Coronavirus), the virus that causes Covid-19. These variants might be partially resistant to antibodies. However, very little attention has been paid to T cells, especially “killer” CD8+ T cells. Unlike antibodies, T cells do not prevent infection because they get into action only after a virus has infiltrated the body but they are important for ongoing infection. Therefore, in the case of Covid-19 killer T cells could mean the difference between mild infection and a severe infection that requires hospitalisation and death. These killer T cells recognise viruses and kill viruses-infected cells. Since viruses require cells for their survival and multiplication, killer T cells may eliminate cellular factories for coronavirus. The evidence for an important role of T cells in defence against coronavirus comes from patients who are born with genetic defects of the immune system with failure to make any antibodies including antibodies against coronavirus.
An international study in which we participated and other studies by us and others of patients with primary antibody deficiency diseases with genetic defects of the immune system who contract coronavirus infection and did not make antibodies against coronavirus had either a mild disease and did not require hospitalisation and those who required hospitalisation recovered from Covid-19. There were no deaths if they did not have any other comorbid conditions. Many of these patients have no B cells to produce antibodies. If antibodies were critical, we would have expected these patients to have serious Covid-19 and many deaths. Therefore, even though we may not produce antibodies, T cells especially “killer” T cells may keep us alive.
The role of T cells may also be important when we consider different vaccines, especially against mutant strains. However, before we consider the vaccine, we should consider a few facts about mutations. RNA viruses are very prone to mutations so mutations in SARS-CoV-2 should not come as a surprise. When viruses mutate they change their characteristics, they could become more transmissible (infectious) but not pathogenic (disease-causing), or they may not change transmissibility but become more pathogenic, or they may become more infectious and more pathogenic. SARS-CoV-2 mutations (UK, Brazil, South Africa) have shown to be more infectious, however, there is limited data on the pathogenicity.
In a recent study, a researcher has shown that South African mutants (B.1.351) were partially resistant to antibodies raised against various coronaviruses, however, T cells were active against this variant because T cells did not target the region of the virus that were mutated. All except one (COVAXIN) vaccine are targeting spike protein where the majority of mutations occur including against receptor-binding domain (RBD). Therefore, a vaccine that is targeted against spike protein may not be fully effective against mutant strains. However, a vaccine using the inactivated whole virus (COVAXIN) is likely to elicit both antibody and T cell responses against all components of the virus including membrane, envelope, and nucleocapsid proteins. Therefore, in mutated strains of the virus, the killer T cell should be able to recognise non-mutated components of the virus, kill virus-infected cells and clear the infection.
We should also remember a basic difference between ‘natural immunity’ that is acquired after infection and ‘vaccine-induced’ immunity. Natural infection induces “sterile” immunity, whereas vaccine induces “protective immunity”. In the case of Covid-19, virus infections start from the mouth, nose, and upper respiratory tract where major protective antibodies are Immunoglobulin A (IgA), whereas in the lower respiratory tract and lung, major protective antibodies are Immunoglobulin G (IgG). Intramuscular vaccination induces a systemic response predominantly of IgG antibodies. Therefore, a vaccinated individual may still contract and transmit the infection but may not have a serious disease. Hence, we should continue to wear a mask even after receiving the vaccine until we have reached herd immunity. How long the immunity would last from natural infection versus vaccine requires further study of both memory antibody-producing B cells and effector memory T cells.
The writer is a professor of medicine, microbiology, and molecular genetics, the University of California, Irvine, USA.
Hearing loss is treatable if detected timely, say doctors
Children can grow up to lead normal lives if hearing disabilities are detected early. For that, a universal screening programme and creating awareness among parents are important initial steps, suggest ENT specialists.
New Delhi: Disabilities related to hearing have become a big concern as the WHO has also said that nearly 2.5 billion people worldwide or one in every 4 individuals will have some degree of hearing loss by 2050. Top experts Dr Alok Thakar, HoD of ENT at AIIMS, Dr Sumit Mrig, senior consultant and HoD of ENT at Max Hospital, and Dr Prachi Jain, ENT specialist at Alchemist Hospital, suggest that early detection and awareness can protect people from many hearing-related problems.
Q: Why is hearing loss usually neglected?
Dr Thakar: Hearing loss is often a silent disability because people who have hearing loss generally withdraw from social interaction slowly. The simple reason for that is that they can’t participate fully. The problem with hearing loss is also that leads to significant slow effects which are not easily recognised. It can lead to decreased language development in younger children and academic performance in school-going children. It does lead to cognitive or mental decline and dementia for elderly people who can’t hear well too.
Q: Does it affect people psychologically?
Dr Thakar: Yes, they are probably affected psychologically but we have not proven it scientifically. Unfortunately, hearing loss or hearing damage is very minimal and cumulative, which means it adds up over the years. It happens primarily because of noise as we live in very noisy environments, which are not safe for us. We also use earphones all the time for using the phone or listening to music, but the effects of that will show as age increases.
Q: Do you think working from home is a reason for hearing issues now?
Dr Thakar: Certainly. Earphones, especially poor-quality ones, if used at loud volumes, are an issue. Otherwise, for conversation, there is no issue. Using earphones for music can be a problem because music has highs and lows and a sudden increase in volume and amplitude can lead to ear damage.
Q: What are other reasons for hearing issues among the general public?
Dr Mrig: I would say that the most common reasons for hearing loss are draining ears, discharging ears, age-related problems and congenital problems. I see a lot of patients who have hearing loss from their first year but don’t get to know about it till they focus on the fact that they are not able to perceive sounds. In fact, people realised they have hearing loss when they were sitting at home during Covid. They were not able to focus on it otherwise in their busy schedules. The incidence of unilateral hearing loss is also very high. A wide spectrum of hearing loss affects all age groups, starting from newborns who are born congenitally deaf to children of lower socio-economic status who go to school with draining or discharging ears and never get it checked. Less than 1% of people go deaf suddenly. Most of them have acquired deafness which keeps on accumulating with discharging ears, causing the erosion of the ear bone, ear ossicles and, finally, the main organ.
As Dr Alok said, hearing loss is a silent killer. When a child is born, if you don’t have a program in practice like a universal newborn hearing screening program, the child will never be able to tell that they can’t hear. Then there are adolescents who might be using lots of headphones or who live in a noisy environment. Then we have the geriatric age group who ignore slow and progressive hearing loss and adapt to it without any interventions. If we have to address the problem of hearing loss in our country, we have to think of the most basic things. Every child in India should be screened for hearing loss. Four in every thousand children born in India may suffer some kind of hearing loss and every year about a lakh kids are born with some kind of hearing loss or deficiency. It might be shocking to hear what the WHO has said today but even now one in five people in the world have some kind of a hearing disability.
Dr Jain: As Dr Sumit said, a universal screening program is very important. At least, a high-risk pregnancy screening programme should be thoroughly followed. Any child who had antenatal events or who was born to a mother who was deaf, or had a high-risk pregnancy, or was a patient who was on fentin or any drugs, or has any kind of infection like rubella needs to be screened thoroughly. Same for any patient who had a prenatal history, did not cry at birth, had high bilirubin or was later given drugs which affect hearing like aminoglycoside, cisplatin or chloroquine. People should get audiometry or evaluation before starting such drugs, and afterwards, periodic assessment should be done.
Q: What are age-related hearing problems?
Dr Thakar: It is when people slowly develop hearing loss when they are over the age of 60. Unfortunately, many people are developing hearing loss before that age too. The prime reason is noise exposure during adulthood or mid-life, which slowly accumulates. There is a very interesting study which shows that tribal populations from Africa who were not exposed to loud music or drums never developed age-related hearing loss. It is only with people who live in civilized society because we are exposed to such noise.
Q: How harmful is using earbuds when the ears itch?
Dr Mrig: When you use an earbud, you actually push the wax deep inside which cannot be taken out. I, as an ENT surgeon who knows the length of my ear canal, have not been able to take out my wax using an earbud. I have seen people use the back of a pencil or pen, car keys, earbuds and toothpicks which can cause damage to the very delicate epithelium inside the ear canal and the skin, causing infection. I see close to three or four cases every month where there is a traumatic perforation or a hole in the ear drum, where a person was trying to clean their ear and a child came running from behind and caused trauma. So, earbuds should be discouraged.
Q: For timely cleaning, should people visit a doctor?
Dr Mrig: When I was at Maulana Azad, we did a lot of programmes where we covered close to 15-20 schools and where the National Program for Deafness started. You would be surprised to know how accumulation of earwax may be a reason for hearing loss in a child. A child may accumulate a lot of impacted wax that can cause about 25% to 30% of hearing loss, but since he is a child, he is not aware about it. So, awareness and annual checkups by an ENT surgeon will help.
Q: What are the latest technologies to treat hearing issues?
Dr Mrig: The most important technology to treat such issues depends upon the cause of hearing loss. Like I said, with a universal screening program, you can have a basic test which can detect whether a child will hear or not. Once a child fails on the SCOI and on the BERA, you diagnose the child with profound bilateral hearing loss, where hearing loss is more than 90%. So, this lets you detect deafness by one month, establish a diagnosis by three months and intervention should be possible by six months. These newborn cases diagnosed with severe or profound loss should then be counselled for cochlear implant surgery. It is an ear surgery where you place an electronic device which has certain electrodes. There is an external processor too. So, the device serves as a bionic sense organ or artificial ear and carries the sound from the external and internal environment and converts it into signals which go to the brain, which you perceive as sound.
Q: Cochlear implant is very costly. Are there any affordable substitutes?
Dr Mrig: Let me take away the myth that it is a costly surgery. The Government of India helps through different schemes, state program funding and central program funding. More than 300 institutions in the country offer this implant. Dr Alok is part of AIMS, which offers this surgery free of cost. The problem is not the cost of the surgery. In fact, every year, more than 3,000 implants are sanctioned by the government for free implantation to be used by surgeons for deaf kids. The problem is awareness and not detecting it early. By the time these kids reach any surgeon, they are already 3 or 4 years. So, if we are able to identify these children as early as six months and get them implants by eleven months, which is approved by the US FDA and which we follow in India, then these children will have a normal life. The problem is that we don’t have the standardized universal hearing screening program in our country. Last year, on 3 March, I, along with representatives from AOI, met Dr Harsh Vardhan and gave him a proposal. Unfortunately, we all got stuck due to Covid. My sincere request to policymakers and the health ministry is to implement the universal newborn hearing program. Kerala is the only state which has been doing this for the last 2-3 years. Rajasthan, Gujarat and Andhra Pradesh have this program rolled out on paper not in practice.
Q: How can we spread awareness about hearing impairment among parents and children?
Dr Thakar: I think we first need to realize that this is a problem that has a significant impact on how people develop and interact with society and on their economic potential. Three major causes of hearing loss today are presbycusis, discharging ears and early onset presbycusis. Hearing is the only sense which we can replace using technology in a fairly accessible and cost-effective way. And there is funding available. But we are at a stage where screening is necessary. For schoolchildren who cannot perform in school because of hearing and speaking impairment, operation can be done, but they need to be referred to one of us. So, a school healthcare program would help there. Lastly, when you tell us that 700 million will have this problem 30 years from now, it is going to be people of your and my age. So, we need to be careful and take care of our ears by not using earphones, not going to noisy events and places and not using big speakers.
GUIDELINES FOR DM IN MEDICAL GENETICS RELEASED BY NMC
The National Medical Commission has released guidelines for the new competency-based PG training programme for DM in Medical Genetics. This course provides a new opportunity of super specialisation for all those doctors who have completed their PG degree in Medicine, Paediatrics or Obstetrics and Gynaecology.
The guidelines include the specific objectives of the course stating that competency-based training for DM in Medical Genetics aims to produce a postgraduate student who after undergoing the required training should be able to deal effectively with the needs of the patients, community and should be competent enough to handle medical problems related to genetic disorders. These include clinical evaluation, investigations, genetic work-ups requiring pre-test and post-test counselling, up-to-date information and abilities to carry out novel treatments and skills for planning and implementation of population-based prevention programs. Last but not least, be ready for carrying out clinical practice of personalised medicine in the 21stcentury molecular medicine era. The post-graduate student should also acquire skills to teach Medical Genetics to undergraduates and paramedical students as well.
DELHI HC SEEKS AFFIDAVITS FROM BHARAT BIOTECH AND SII ON CAPACITY
The Delhi High Court has asked Serum Institute of India and Bharat Biotech to disclose the capacity they have to manufacture Covaxin and Covishield vaccines, respectively. A bench of the Delhi High Court comprising Justice Vipin Sanghi and Rekha Palli directed the Centre to explain in its affidavit the reasons behind keeping the vaccination drive strictly under the government’s control. The court directed the oganisations to file the affidavit to clarify the capacities to produce Covisiled and Covaxin per day/week/month. The court said, “We are either donating or selling off the vaccines to other countries without looking at our own needs. There has to be a sense of urgency about this.”
SII WRITES TO PMO ON REFORMS IN DRUG REGULATORY SYSTEM
The world’s largest vaccine production company, Serum Institute of India (SII), has written a letter to the PMO on reforms in the existing drug regulatory system, including allowing companies manufacturing and stockpiling of non-Covid vaccines while undergoing clinical trials. In the letter Prakash Kumar Singh, who is the Director of Government and Regulatory Affairs at the Pune-based SII referred to the Union Health Ministry’s 18 May 2020 gazette notification, saying it allowed manufacturing and stockpiling of Covid-19 vaccine under clinical trial for marketing authorisation sale or distribution.
In the letter, Prakash Kumar Sing wrote, “Because of this rule, it became possible for us to manufacture and stockpile the Covid-19 vaccine during clinical trials and we could make the vaccine available in such a span of time to protect millions of lives.”
THERE’S NO CO-WIN MOBILE APP FOR COVID VACCINE REGISTRATION: R.S. SHARMA
R.S. Sharma, chairman of Empowered Panel for Covid-19 Vaccination and chief of Co-WIN, exclusively spoke to The Sunday Guardian and clarified doubts about Covid-19 vaccine registration and complaints of technical glitches on the portal.
Q. What are the problems people are facing? They are not aware and still confused about the Co-WIN. What information would you share?
A. I would like to inform the viewers that we have not created any app. There is no app called Co-WIN Mobile App. What happened is that the previous government App, Arogya Setu, the purpose of which was to track and trace the infection has got an extension called the Co-WIN registration and scheduling. We have created a portal www.cowin.gov.in which enables you to register yourself and your family members for vaccination. Up to four registrations linked to a mobile number has been allowed which is pretty simple: Enter your mobile number; you will get an OTP; and get registered along with 3 more individuals
There is a video with the instructions available on the website. All in all, there is an Arogya Setu app and a portal for registration.
Q. What are the identity proofs required for registration?
A. No Id proof is required for registration. At the time of registration, you will be asked as to which Id will you be bringing to the centre and there are 6-7 approved Id’s that can be brought, any of which contains your photograph, name, gender, and DOB. Some of these Id’s are: Aadhaar Card; Driving Licence; Passport; Voter Id Card; Pan Card.
When you enter the centre, you will be asked for your Id number. If you are above 60 years of age, you do not need any other document except the Id proof but if you are between 45-59, you will require a medical certificate for your co-morbidity in addition to your Id proof because as per the rules only these people can be essentially vaccinated. The document is necessary as it will be photocopied and uploaded.
Q. In many cases, people come across technical glitches while registering themselves with the app. Are you getting such complaints too?
A. I haven’t got any such complaint until now, the only condition is that you need to use the right platform. Many people are using an “app” that doesn’t exist. Otherwise, there is no scalability issue because our system can take as many registrations as possible.
Q. If in case the registered beneficiary isn’t able to visit the centre at the time of vaccination due to any reason, what would be the other option?
A. In this case, please cancel and reschedule your appointment. If you can do it well in advance before the time of the visit, it will be better as someone else can take that vacancy. It is not advisable to occupy the vacancy and not go as you are wasting somebody else’s claim.
Q. Is walk-in also an option if somebody could not register?
A. Yes, walk-in is allowed but it is advised to register the appointment as it ensures the claim on your vaccine. If you do not register, maybe the vacancy might not be available and you may have to return without getting a jab.
Q. Earlier, we informed the Government of India about the fake apps. What would you say about this?
A. Awareness should be spread so that people are disbarred from using these fake apps. And as I explained, there are only two legitimate modes of registering onto the system, one is Arogya Setu, and the other one is the portal. These should be used.
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